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20171116 900885 Post-inspection Evidence appendix template v3

Sheffield Health and Social Care NHS

Foundation Trust

Evidence appendix

Fulwood House Old Fulwood Road Sheffield South Yorkshire S10 3TH Tel: 01142716310 www.shsc.nhs.uk

Date of inspection visit:

30 May to 5 July 2018

Date of publication:

5 October 2018

This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.

Trust-wide leadership

Facts and data about this trust Sheffield Health and Social Care NHS Foundation Trust provide mental health, learning disability,

substance misuse, community rehabilitation, primary care, specialist services and adult social

care services.

It serves the 563,000 people of Sheffield. The trust employs 2,700 staff and provides services

from 42 community and inpatient sites with more than 150 beds across the city. It has an annual

budget of £128 million.

The trust was established in 2003 as Sheffield Care Trust and on 1 July 2008 became Sheffield

Health and Social Care NHS Foundation Trust. It works with one clinical commissioning group,

NHS Sheffield CCG. The trust has been registered with the CQC since 1 April 2010.

The trust provides primary medical services, mental health inpatient and community services and

adult social care.

The trust provides services that are commissioned by:

• NHS England

• Sheffield Clinical Commissioning Group

• Sheffield City Council

The trust provides the following services:


• Acute mental health wards and psychiatric intensive care units for adults of working age

• Long stay rehabilitation mental health wards for adults of working age

• Forensic inpatient/secure wards

• Wards for older people with mental health problems

• Wards for people with learning disabilities or autism

• Community-based mental health services for people with learning disabilities or autism

• Community-based mental health services for older people

• Community-based mental health services for adults of working age

• Mental health crisis services and health-based places of safety

• Substance Misuse services

• Primary medical services

• Adult social care services

The CQC has previously inspected locations registered to Sheffield Health and Social Care NHS

Foundation Trust on 26 occasions. These inspections took place between October 2014 and

November 2016.

The trust had 11 locations registered with the CQC (on 8 June 2018). Registered location Code Local authority

Assessment and Treatment Service (ATS) TAHEC MH South Yorkshire and Bassetlaw Area Team

Clover City Practice TAHX4 PMS South Yorkshire and Bassetlaw Area Team

Forest Close TAHXM MH South Yorkshire and Bassetlaw Area Team

Forest Lodge TAHXN MH South Yorkshire and Bassetlaw Area Team

Fulwood House TAHXK MH South Yorkshire and Bassetlaw Area Team

Grenoside Grange TAHXP HSP South Yorkshire and Bassetlaw

Jordanthorpe Health Centre TAH54 PMS South Yorkshire and Bassetlaw Area Team

Michael Carlisle Centre TAHFC MH South Yorkshire and Bassetlaw Area Team

The Longley Centre TAHCC MH South Yorkshire and Bassetlaw Area Team

Wainwright Crescent TAHYR ASC North Central Hub 2

Woodland View TAH95 ASC Central East Midlands Hub 1

The trust had 157 inpatient beds across 12 wards, none of which were children’s mental health beds. The trust had no outpatient clinics a week and 450 community clinics a week.

Total number of inpatient beds 157


Total number of inpatient wards 12

Total number of day case beds 0

Total number of children's beds (MH setting) 0

Total number of children's beds (CHS setting) 0

Total number of outpatient clinics a week 0

Total number of community clinics a week 450


Is this organisation well-led?

Leadership

The trust board had the appropriate range of skills, knowledge and experience to perform its role.

The board comprised five executive directors, including the chief executive with career experience

in a healthcare setting and relevant qualifications as appropriate for their leadership roles. There

were also two non-voting directors and six non-executive directors, including the chair that

brought experience of business, finance, health and social care. Non-executive directors used the

knowledge and skills from their relevant backgrounds to provide appropriate challenge at board

meetings through robust questions and challenges. We saw that this was accepted and

responded to openly and positively by the executive team.

There was an open and patient focused culture. The senior leadership team displayed integrity in

their decision making and actions. The trust board engaged in regular board development

sessions. A recent session was used to develop the board assurance framework and future

sessions were planned to consider strategy and development. Non-executive directors had

undertaken joint development sessions with the trust’s governors.

The leadership team had comprehensive knowledge of the current priorities and challenges

across all sectors and were taking action to address them. They were aware of the trust’s

priorities and ambition for the coming years. However, there had been deterioration in services

since the last inspection, which the trust leadership team had not recognised and this resulted in

the reduction in the overall ratings for two of the ten core services at this inspection. The chair,

chief executive and other executive directors expressed concern regarding the trusts

management capacity to fulfil all of its projects and commitments going forward.

The executive board had 20% black and minority ethnic members and 20% of the executive

board were women.

The non-executive board had 17% black and minority ethnic members and 83% of the non-

executive board were women.

BME % Women %

Executive 20% 20%

Non-executive 17% 83%

Total 18% 55%

Directors, or equivalent, must be of good character, have the necessary competence, skills and

experience and be physically and mentally fit enough to fulfil the role. They must also be able to

supply information including a Disclosure and Barring Service check and a full employment

history. We reviewed the personnel records of the executive and non-executive directors who had

joined the trust since our last inspection. All were compliant with the requirements of the fit and

proper person regulation.

The executive team were supported by a senior leadership team which consisted of a full time

director and clinical director of operations and transformation accountable for all clinical

services. There were also three associate directors; two covering the care networks and one for

patient safety. The care network associate directors worked in partnership with designated clinical


directors, to which there were five. There was a designed deputy director of nursing (operations)

reporting into the director and clinical director of operations, jointly accountable to the chief nurse.

The director of nursing was the executive lead for safeguarding adults and children and there was

a full-time safeguarding lead and a named nurse for safeguarding. Dedicated senior nurses were

in place and supported with physical health, resuscitation and infection prevention and control.

The director of nursing spoke positively regarding leadership that would be provided by the newly

introduced director role for allied health professionals and the director for psychological services

and therapies. She also spoke about the investment in in senior nursing roles and the clear

pathway for nurses in the trust and felt nurses were being valued by the trust.

Interim arrangements for the pharmacy service over the last 22 months had caused some impact

on staffing levels and reduced capacity to ensure policies and procedures were regularly

reviewed. This meant that staff were using out of date policies and guidelines relating to

medicines. The trust had recently appointed a new chief pharmacist who was accessible to all

staff. They were aware of the challenges to the quality and sustainability of the pharmacy service,

and plans were in place to address these. However, these plans had not yet had an impact on the

service.

The trust supported staff and offered training in a variety of leadership development initiatives at

all levels of the organisation. Leadership was an integral part of the workforce and organisational

development strategy. It had a delivery plan which set out objectives to deliver the leadership and

talent management strategy.

The trust offered skills training in management areas such as human resources and finance. It

was also formalising this into an induction programme for new managers. Managers had access to

tools for self-assessment and 360 feedback against the NHS Leadership Qualities Framework. An

in-house leadership development workshop provided preparation for appraisal conversations.

Leadership skills training was also available through short courses and electronic learning. In

addition, the trust could organise bespoke external provision where a learning need was identified

through appraisal.

Institute of Leadership and Management Accredited leadership qualifications were offered through

apprenticeship pathways at Level 3 and Level 5. These were delivered in partnership with other

local trusts and training providers. Apprenticeship pathways offered an opportunity to improve the

recruitment and retention of staff. These routes offered opportunities for leadership training at

different levels of the organisation including support staff team leaders.

Staff also had access to the accredited degree programmes such as NHS Leadership

programmes and graduate routes. The trust were a higher than average organisation for staff

accessing leadership programmes such as the Nye Bevan programme, specifically designed to

develop senior leaders and the Mary Seacole programme, a six month leadership development

programme which was designed by the NHS Leadership Academy.

The trust had a bespoke coaching service, which offered time with an accredited coach to

increase performance. Eight coaches were accredited to Institute of Leadership and Management

level five with a further four undertaking accreditation. On inspection,126 staff had received

coaching.

Other initiatives included leadership development workshops and leadership engagement network

events. In these events, the chief executive met with frontline leaders to converse, listen and

interact directly.


Vision and strategy

The trust vision and values had been developed in consultation with patients, governors and staff. The vision was to improve the mental, physical and social wellbeing of the people in our communities. The vision was underpinned by values of:

• Respect – we listen to others, valuing their views and contributions.

• Compassion – we show empathy and kindness to others so they feel supported, understood and safe.

• Partnership – we engage with others on the basis of equality and collaborations.

• Accountability – we are open and transparent, acting with honesty and integrity, accepting responsibility for outcomes.

• Fairness – we ensure equal access to opportunity, support and service.

• Ambition – we are committed to making a difference.

The trust described these values as the guiding principles and behaviours for the way they do their work. These guiding principles were further supported by a number of specific aims, which were:

• Working with and advocating for the local population.

• Refocusing services towards prevention and early intervention.

• Continuous improvement of services.

• Locating services as close to peoples' homes as they can.

• Developing a confident and skilled workforce.

• Ensuring excellent and sustainable services.

The vision and values were very well embedded in the organisation. The senior executives referred to the trust vision and values throughout the inspection. Staff throughout the organisation were familiar with the values and their practice was valued driven. Staff recruitment and appraisals were centred on the trust values, thus ensuring that all staff were familiar with the trust values from the outset.

The trust had developed a strategy to enable it to achieve the vision and aims. This was approved by the trust board in June 2017. When developing the strategy, a range of engagement activities were undertaken to seek feedback and views from stakeholders. This included service user groups, staff and the council of governors. They also consulted with external partners to review and explore alignment across city wide plans and local needs. The strategic aims were:

• Quality & Safety Aim: We will provide high quality care and support as early as possible in order to improve physical, mental and social wellbeing.

• People Aim: We will promote a culture of collaboration, supporting people to work together to make a difference.

• Future Services Aim: We will develop excellent mental, physical and social wellbeing for the communities we serve through innovation, collaboration and sharing.

• Value for Money Aim: We will provide sustainable services through ensuring value for money, reducing waste and unproductive time for our staff.

The quality and safety aim had led to an improvement in the safety of only one of the core services inspected and the rating for the crisis and health based places of safety had seen its rating in the safe domain reduced to inadequate at this inspection.


The trust had a strategy for meeting the physical healthcare needs of patients and had a lead nurse in place to support the implementation. The trust had also conducted a number of clinical audits in relation to physical health care with associated plans for improvements where these had been identified. However, there were inconsistencies in the standard of physical health care across the trust, for example in the acute wards for adults of working age and psychiatric intensive care units staff were ensuring that patients received a comprehensive physical health assessment on admission, but did not always undertake the required physical health monitoring following the administration of rapid tranquillisation.

The trust medicines optimisation strategy, which had been developed in partnership with senior pharmacy staff and other key stakeholders, was approved in April 2018. There was no mechanism in place to monitor progress against delivery of the strategy. However the newly appointed chief pharmacist was aware of this and had plans to improve monitoring in the future.

Culture

The trust had an open and honest culture. An example of this was demonstrated by the openness with which the executive team responded to staff and patient concerns. The chief executive was visible and accessible to staff and responded in person to discuss concerns raised by staff. He also offered face to face meetings with patients or carers who had made a formal complaint. Non-executive directors regularly visited frontline services.

Staff were aware of the trust’s whistleblowing policy and they knew who the trust’s freedom to speak up guardian was. The freedom to speak up guardian had regular meetings with the chief executive and we saw instances of where the freedom to speak up guardian had supported staff to raise concerns. Staff knew how to raise concerns and told us they could do this without fear of retribution. Managers had introduced externally facilitated team meetings to enable staff to express their concerns and suggest improvements.

In the 2017 NHS Staff Survey, the trust had better results than other similar trusts in four key areas:

Key finding Trust score Similar trusts

average

KF7 Percentage of staff able to contribute towards improvement at work 75% 73%

KF11 Percentage of staff appraised in last 12 months 95% 89%

KF16 Percentage of staff working extra hours 70% 72%

KF24 Percentage of staff / colleagues reporting most recent experience of

violence

94% 93%

In the 2017 NHS Staff Survey, the trust had worse results than other similar trusts in 23 key areas:

Key finding Trust score Similar trusts average

KF1 Staff recommendation of the organisation as a place to work or receive

treatment 3.47 3.67

KF2 Staff satisfaction with the quality of work and care they are able to

deliver 3.59 3.83

KF3 Percentage of staff agreeing that their role makes a difference to

patients / service users 82% 88%


Key finding Trust score Similar trusts average

KF4 Staff motivation at work 3.71 3.91

KF5 Recognition and value of staff by managers and the organisation 3.44 3.59

KF6 Percentage of staff reporting good communication between senior

management and staff 31% 36%

KF8 Staff satisfaction with level of responsibility and involvement 3.80 3.88

KF10 Support from immediate managers 3.81 3.95

KF12 Quality of appraisals 2.92 3.22

KF13 Quality of non-mandatory training, learning and development 3.96 4.06

KF14 Staff satisfaction with resourcing and support 3.20 3.35

KF15 Percentage of staff satisfied with the opportunities for flexible working

patterns 56% 60%

KF17 Percentage of staff feeling unwell due to work related stress in the last

12 months 51% 42%

KF18 Percentage of staff attending work in the last 3 months despite feeling

unwell because they felt pressure from their manager, colleagues or

themselves

58% 53%

KF19 Organisation and management interest in and action on health and

wellbeing 3.66 3.77

KF20 Percentage of staff experiencing discrimination at work in the last 12

months 17% 14%

KF21 Percentage of staff believing that the organisation provides equal

opportunities for career progression or promotion 81% 85%

KF22 Percentage of staff experiencing physical violence frim patients,

relatives or the public in the last 12 months 24% 22%

KF25 Percentage of staff experiencing harassment, bullying or abuse from

patients, relatives or the public in the last 12 months 38% 32%

KF28 Percentage of staff witnessing potentially harmful errors, near misses

or incidents in last month 34% 27%

KF30 Fairness and effectiveness of procedures for reporting errors, near

misses and incidents 3.55 3.75

KF31 Staff confidence and security in reporting unsafe clinical practice 3.60 3.71

KF32 Effective use of patient / service user feedback 3.41 3.72


The executive team were aware that the results of the staff survey were worse than in previous

years. The trust had recently undergone a large community service transformation and a

management restructure in a short period, which the chief executive described as an

unprecedented degree of change. The chief executive reflected that it had been a mistake to

undertake both projects so close together and that initial learning had been taken from that as well

as commissioning an external review.

Following the organisational changes, some staff felt their concerns regarding the re-configuration

of community services were not being heard and responded to. However, we found that the

executive team were aware of the concerns raised and had committed to listen to staff. Senior

managers had organised externally facilitated team meetings to ensure staff felt able to express

concerns and the chief executive has responded personally to concerns raised. Prior to the results

of the staff survey, they had also commissioned an externally facilitated review of the service

reconfiguration that would include patient safety, experience and staff views in the terms of

reference. In addition, the trust had held a learning from change event. The purpose of this was to

provide an opportunity to share experiences of change, to understand support needs throughout

the process, improve practice and update policy.

The executive team were visible and spent time in the services with patients and staff. These visits

formed part of the 15 Steps Challenge. The 15 Steps Challenge uses some of the principles of

mystery shopping and observational approaches. It aims to understand what service users and

carers experience when they first arrive in a mental healthcare setting. The chief executive spent

one day each month working as a support worker in different areas of the trust, he also used this

opportunity to listen to staff concerns. The deputy chief executive visited clinical areas outside of

office hours and on bank holidays. The medical director also ran patient assessment clinics within

the single point of access within the trust. During our interview with the director of nursing it was

clear that she had in depth knowledge of the staff and services in the trust.

Staff working in core services told us they felt supported by their managers and senior managers

were visible and approachable. Most staff, at all levels in the organisation felt respected,

supported and valued, however, staff morale within the crisis and health based place of safety

service was low. Staff demonstrated commitment, positivity and enthusiasm in their positions and

in the work they completed. Despite some staff feeing that recent organisational changes had a

negative impact, all were very passionate and cared about the service they provided.

The trust rewarded staff and volunteers through annual recognition and achievement awards.

There were also a number of initiatives in place to support staff. These included access to cheaper

loans for staff through a neighbouring organisation, salary sacrifice schemes for bicycles and cars

and staff rotation opportunities.

The trust worked with the trade unions and professional organisations. There were monthly

meetings attended by the deputy and chief executive to identify, discuss and where possible

resolve issues. Trade union representatives described the trust as very fair and approachable.

They were involved in policy development and consultation and had recently facilitated a

meaningful consultation workshop for members of the human resource department. The trust had

a redeployment policy in place and 80 percent of staff were redeployed successfully during the

reconfiguration of services and there had been no staff redundancies. The trust had received no

grievances from staff in relation to the process.


Managers at all levels of the organisation provided examples of where poor performance had been

addressed in line with the trust’s disciplinary policy and procedure. We reviewed five disciplinaries,

all of which adhered to the trust’s disciplinary policy and procedure. Investigations were thorough,

and clearly explained outcome letters offered the staff member including the right of appeal

against any sanction, with staff being supported through the process by union or other

representatives. One case could have been dealt with in a more timely way, this was

acknowledged in the outcome letter and an apology given. Trade union representatives felt that

the trust treated staff fairly and would reschedule disciplinary meetings to enable the staff

members to be supported by an appropriate representative.

We reviewed two grievances against the trust, both adhered to the policy and investigations were

thorough. Neither case was upheld, however, in one case the investigation found that trust

procedures had not been followed.

The trust had policies and procedures in place to support clinical professional registration

verification and criminal records checking and disclosure and barring which were clear and easy to

understand. However, some of the terminology in the clinical professional registration verification

policy was out of date and the appendices in the criminal records checking and disclosure and

barring policy were in draft form. Although the trust had systems in place to monitor staff

compliance with these policies, it was acknowledged that it had not been monitored and managed

systematically since the member of staff who had dedicated responsibility for monitoring

compliance left 18 months ago. However, we did not find that staff were working without the

necessary registration and clearance.

The trust gained regular feedback from the Friends and Family Test, which was collated and analysed centrally and subsequently fed back at individual service level monthly for local action.

The Patient Friends and Family Test asks patients whether they would recommend the services they have used based on their experiences of care and treatment. The trust scored between 6% and 8% higher than the England average for patients recommending it as a place to receive care in all six months between November 2017 to April 2018.

February 2018 saw the highest percentage of patients who would recommend the trust as a place to receive care with 97%, however each month in the period scored 94% or above.

The trust scored lower than the England average in terms of the percentage of patients who would not recommend the trust as a place to receive care in all six months from November 2017 to April 2018.

Trust wide responses England averages

Total eligible

Total

responses

% that would

recommend

% that would

not recommend

England average

recommend

England

average not

recommend

November 2017

17982 190 94% 3% 87% 5%

December 2017

17024 127 94% 1% 88% 4%

January 2018

17689 153 95% 1% 88% 4%

February 2018

17584 144 97% 1% 89% 4%

March 2018

9688 124 95% 2% 89% 4%

April 9953 143 96% 1% 89% 4%


2018

Last year the trust signed up to an enhanced feedback service with Care Opinion. It is a non-profit community interest company that provides a feedback platform for health and social care in an attempt to increase service user feedback regarding their services. The trust had 24 champions trained to manage, act upon and respond to service user feedback.

The trust also used other satisfaction questionnaires. These included the Quality & Dignity questionnaire, discharge questionnaires and microsystem improvement questionnaires. Additional opportunities for providing feedback were available such as through the trust website, focus, advocacy and participation groups.

Examples of changes and improvements as a result of patient and carer feedback included changes to the visiting hours in the older peoples wards, an increase in the activities available on the rehabilitation wards and changes to the format and font size of letters sent out to patients and carers in the community mental health services for older people with mental health problems.

The Staff Friends and Family Test asks staff members whether they would recommend the trust as a place to receive care and also as a place to work. Quarter 4 2016/2017 had the highest scores for staff recommending the trust as a place to receive care. Quarter 1 2017/2018 had the highest scores for staff recommending the trust as a place for work.

There is no reliable data to enable comparison with other individual trusts or all trusts in England.

The graphs below show the percentages of staff who would recommend the trust for work and for

care:

Definition

Substantive – All filled allocated and funded posts.

Establishment – All posts allocated and funded (e.g. substantive + vacancies).

Substantive staff figures Trust target

Total number of substantive staff At 31 January 2018 1351.6 N/A

Total number of substantive staff leavers 1 February 2017 to 31 January 2018

129.6 N/A

Average WTE* leavers over 12 months (%) 1 February 2017 to 31 January 2018

8% 13%


Vacancies and sickness

Total vacancies overall (excluding seconded staff) At 31 January 2018 68 N/A

Total vacancies overall (%) At 31 January 2018 5% N/A

Total permanent staff sickness overall (%)

Most recent month (At 31 January 2018)

8% 5%

1 February 2017 to 31 January 2018

7% 5%

Establishment and vacancy (nurses and care assistants)

Establishment levels qualified nurses (WTE*) At 31 January 2018 32 N/A

Establishment levels nursing assistants (WTE*) At 31 January 2018 433 N/A

Number of vacancies, qualified nurses (WTE*) At 31 January 2018 7% N/A

Number of vacancies nursing assistants (WTE*) At 31 January 2018 15 N/A

Qualified nurse vacancy rate At 31 January 2018 353 N/A

Nursing assistant vacancy rate At 31 January 2018

4% N/A

Bank and agency Use

Shifts bank staff filled to cover sickness, absence or vacancies

(qualified nurses) 1 February 2017 to 31

January 2018 4977 (15%) N/A

Shifts filled by agency staff to cover sickness, absence or vacancies

(Qualified Nurses) 1 February 2017 to 31

January 2018 1629 (5%) N/A

Shifts NOT filled by bank or agency staff where there is sickness,

absence or vacancies (Qualified Nurses) 1 February 2017 to 31

January 2018 900 (3%) N/A

Shifts filled by bank staff to cover sickness, absence or vacancies

(Nursing Assistants) 1 February 2017 to 31

January 2018

21770

(37%) N/A


(Nursing Assistants) 1 February 2017 to 31

January 2018 5623 (9%) N/A

Shifts NOT filled by bank staff where there is sickness, absence or

vacancies (Nursing Assistants) 1 February 2017 to 31

January 2018 1760 (3%) N/A

*Whole-time Equivalent

Staff recruitment and retention was an ongoing challenge for the trust. In the acute wards for

adults of working age and psychiatric intensive care unit, although there was a high ratio of

qualified to unqualified staff on shift, vacancies for qualified nurses were high. There was a

reliance on bank and agency staff to maintain staffing numbers and there were not always the

required number of staff on duty to undertake physical interventions safely. Staff on the wards for

people with a learning disability or autism sometimes had to cancel activities and patient leave due

to there being insufficient staff.

Staff from the community-based mental health services for adults of working age told us that there

were not enough staff to provide an effective service to patients. The trust told us that these

concerns will be considered as part of the planned service review following reconfiguration, which

will be undertaken later this year. The associate director for planned and scheduled care had

developed a business case to increase staffing following feedback from staff and with supporting

evidence from ongoing service monitoring.

The director of nursing described a clear pathway for nurse development with the introduction of

new roles, including nurse associate and nurse consultant roles. She also recognised that the trust


had many staff that were happy in their current roles and these were supported to harness those

within that role. The trust had introduced a preceptorship nurse rotation programme. The deputy

associate director within the crisis and emergency care networks led this initiative and began by

engaging new starters to configure a programme designed to develop their competency as a

nurse.

The trust had recently introduced a scheme whereby staff who work in high stress areas are given

opportunities to undertake secondments, when they were available to other areas of the trust,

such as risk management and safeguarding teams within corporate services. This allowed staff

time away from the stresses of high acuity services and enabled then to develop new skills and

knowledge. The safeguarding team told us they were proud that staff had asked to work with them

and recognised the benefit for the whole organisation through staff taking their knowledge back to

share and apply in operational services.

The board had recently approved a venture to support professions other than doctors to become

responsible clinicians under the Mental Health Act, the lead for this development was a newly

appointed director for psychological services and therapies.

The two highest causes of sickness within the trust were stress and musculoskeletal problems. In

an attempt to reduce absence levels, the trust had introduced a fast track referral to the Improving

access to Psychological Therapy services either within the trust or a partner organisation for any

member of staff. It had also introduced a physiotherapy service for staff, whether at work or absent

due to sickness, at no cost to the individual and without requiring a referral to the occupational

health department. The physiotherapy service also provided workshops across the organisation.

Staff could have a 45-minute consultation. Since the introduction of this initiative musculoskeletal

problems have reduced and are no longer in the top three causes of sickness absence.

The guardian of safe working hours had two hours per week dedicated time for the role. It was

reported as adequate time and this was used flexibly to attend meetings and forums to publicise

the role. This included the medical staffing committee, medical workforce planning committee, the

junior doctors and trust induction. Within the previous12 months, there had been 42 exception

reports. The themes from the reports were inpatient doctors reporting staying late to complete

work for medical emergencies at the end of the day and working more than the 50 percent of time

paid for in specific role on-call. However, the latter was difficult to quantify as there may have been

occasions when the doctor worked less than the 50 percent they were paid for. The trust had

made changes as a result of the themes identified. These changes included encouraging junior

doctors to discuss priorities with supervisors including handing work to others at the end of shift

and educating and supporting doctors to understand they do not have to stay late. A band 7

nursing role had been created on the inpatient wards, an aspect of the role was to identify and

coordinate work during the evenings. Consultants were encouraged to make contact with junior

doctors at handover to ensure they knew there was support available during their shifts. The trust

had not received any penalties in relation to safe working hours.

The trust had a strategy to promote and improve equality diversity and inclusion for black asian

and minority ethnic service users and staff. The trust board had also agreed Workforce Race

Equality Standard targets from 2016 – 2021. The Workforce Race Equality Standard action plan

was incorporated into the reporting against trust targets.

Diversity and inclusion was included within the human resources portfolio and there were

challenges regarding the engagement of operational services. Although, there were more service

objectives and priorities identified in the strategy, the priority was heavily based on the Workforce

Race Equality Standards and in increasing experience and representation in the senior positions


within the trust. The executive directors were active participants in mentoring and received regular

updates, but were not used as the sole means to drive activity in this area.

We saw positive examples of development and opportunities in relation to the black and minority

ethnic priorities, including detailed data based discussions that drove equality impact assessments

and influenced change. There was also senior mentoring to support black and minority ethnic staff

development. The trust had a black and minority ethnic network with information and links to other

publications on the trust website. There were mixed views from the members of the network we

spoke with, but overall these were positive.

The trust’s programme to promote and improve equality, diversity and inclusion for black, asian

and minority ethnic staff won the ‘most effective use of diversity to strengthen governance,

recruitment or promotion’ category at the Healthcare People Management Association Excellence

in Human Resource Management awards 2017. The Healthcare People Management Association

Excellence Awards recognise and reward outstanding work in healthcare human resource

management. Forest Close long stay rehabilitation ward and the community enhancing recovery

team were finalists in the specialist mental health rehabilitation award. G1 and the Respect

training programme had been shortlisted as finalists for the mental health safety improvement

award and the liaison psychiatry service was shortlisted for the integration of physical and mental

health card award in the Positive Practice in Mental Health Awards 2018.

The trust’s Build, Modify, Expand project focused on mentoring staff at all levels across the trust.

The mentoring model involved five members of the board of directors who mentored members of

staff from black and minority ethnic backgrounds in senior positions. At the time of the inspection

the trust was establishing the third cohort, this had involved thirty to forty staff overall. These staff

in turn provided mentoring to members of staff from black and minority ethnic backgrounds in

more junior positions.

The trust relied on a project management approach to support the workforce race equality

standard agenda. This was due to end in the near future and could create a risk to the

organisation if the agenda is not fully embedded within the trust. It was not clear whether an

evaluation would take place. Although the trust had worked hard to promote improvements for the

black and minority ethnic staff group, there was little evidence of the same emphasis on disability,

it was described to us as being at the bottom of a mountain with little focus. The accessible

information standard was not being fulfilled and although there was a plan in place to address this,

there was not enough resource to implement the plan effectively. The intent was positive although

the lack of capacity presented a risk in driving the agenda forward.

As at 28 February 2018, the training compliance for trust wide services was 88% against the trust target of 80%. One training course provided by the trust (Respect Level 1) had compliance rates below the trust target and below 75% at 66%.The training compliance reported for the trust during this inspection was higher than the 77% reported for the previous year. Although there were significant improvements in the compliance with mandatory training since the last inspection staff on the wards for people with learning disabilities and autism and community based mental health services for adults of working age had not completed all elements of their mandatory training. Staff reported that they had access to and were well supported to attend conferences, access specialist training and were able to visit other services.

The trust’s target rate for appraisal compliance was 90%. As at 31 January 2018, the overall appraisal rates for non-medical staff was 96%.


The core services failing to achieve the trust’s appraisal target were ‘MH - Substance Misuse’ with 89%.

Core Service Total number of

permanent non-

medical staff

requiring an

appraisal

Total number of

permanent non-

medical staff

who have had

an appraisal

Appraisa

l rate (%)

MH - Community mental health services for people with learning

disabilities or autism 39 39 100%

MH - Forensic inpatient 55 55 100%

Other 6 6 100%

MH - Long stay/rehabilitation mental health wards for working age

adults. 110 109 99%

MH - Wards for older people with mental health problems 84 83 99%

MH - Mental health crisis services and health-based places of

safety 93 91 98%

MH - Acute wards for adults of working age and psychiatric

intensive care units 181 175 97%

Other - ASC service 116 113 97%

MH - Community-based mental health services for adults of

working age 226 216 96%

MH - Community-based mental health services for older people 119 114 96%

MH - Other Specialist Services 311 300 96%

MH - Wards for people with learning disabilities or autism 28 26 93%

Other - PMS service 48 43 90%

MH - Substance Misuse 79 70 89%

Total 1495 1440 96%

Staff received a values based appraisal and the trust achieved its appraisal target rate. However,

both the chief executive and the director of human resources identified that there was scope for

improvement in the quality of appraisals; although there was no clear plan in place to address this.

The trust’s target rate for appraisal compliance was 90%. As at 31 January 2018, the overall appraisal rates for medical staff was 98%. This was a significant improvement since our last inspection. All of the ten core services achieved the trust’s target appraisal rate.


permanent

medical staff

requiring an

appraisal

Total number of

permanent

medical staff

who have had

an appraisal

Appraisal

rate (%)

MH - Acute wards for adults of working age and psychiatric 5 5 100%



permanent

medical staff

requiring an

appraisal

Total number of

permanent

medical staff

who have had

an appraisal

Appraisal

rate (%)

intensive care units

MH - Community mental health services for people with learning

disabilities or autism 1 1 100%

MH - Community-based mental health services for older people. 11 11 100%

MH - Forensic inpatient 3 3 100%

MH - Long stay/rehabilitation mental health wards for working

age adults 2 2 100%

MH - Mental health crisis services and health-based places of

safety 8 8 100%


MH - Substance Misuse 3 3 100%

MH - Wards for older people with mental health problems 3 3 100%

MH - Community-based mental health services for adults of

working age 11 10 91%

Total 57 56 98%

The trust had a target of 66% for staff receiving clinical supervision. Of concern was at 28 February 2018, the non-medical overall clinical supervision compliance rate was 64%. Six of the eight services in the table below did not meet the trusts target of 66%. The chief executive accepted that this was a governance issue of concern as the trust had not identified the issue prior to the inspection.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. Five of the eleven core services achieved the trust’s clinical supervision target.

Core Service Formal supervision

sessions each

identified member of

staff had in the period

Formal supervision

sessions each

identified member

should of staff have

received

Clinical supervision

rate (%)

MH - Mental health crisis services and health-

based places of safety 491 525 94%

MH - Community mental health services for

people with learning disabilities or autism 114 129 88%

MH - Long stay/rehabilitation mental health

wards for working age adults 281 321 88%

MH - substance misuse 158 184 86%


MH - Community-based mental health services 342 579 59%


Core Service Formal supervision

sessions each

identified member of

staff had in the period

Formal supervision

sessions each

identified member

should of staff have

received


rate (%)

for older people

MH - Wards for people with learning disabilities

or autism 45 81 56%

MH - Community-based mental health services

for adults of working age 155 287 54%

MH - Wards for older people with mental health

problems. 180 363 50%

MH - Forensic Inpatient 42 96 44%

MH - Acute wards for adults of working age

and psychiatric intensive care units. 249 685 36%

Total 2183 3420 64%

The trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months.

In Days

Current

Performance

What is your internal target for responding to* complaints? 3 days 100%

What is your target for completing a complaint? 25 days 71%

If you have a slightly longer target for complex complaints please

indicate what that is here - -

* Responding to defined as initial contact made, not necessarily resolving issue but more than a confirmation of

receipt

**Completing defined as closing the complaint, having been resolved or decided no further action can be taken

Total Date range

Number of complaints resolved without formal process*** in the last

12 months 127

1 March 2017 to

28 February

2018

Number of complaints referred to the ombudsmen (PHSO) in the last

12 months 3

1 March 2017 to

28 February

2018

**Without formal process defined as a complaint that has been resolved without a formal complaint being made. For

example PALS resolved or via mediation/meetings/other actions

A complaints and comments policy was in place, which was clear and easily understood. The

policy identified that complaints should be acknowledged on the day of receipt and an

investigating officer to be identified within three working days. Investigation of the complaint should

be complete within 22 working days and a response provided from the chief executive within 25

working days.

The chief executive was the executive lead for complaints. There was also a non-executive lead.

The day to day responsibility was held by the head of corporate affairs. The total number of staff

dedicated to complaints was the head of corporate affairs supported by a corporate affairs officer


and an administration assistant. The team was without one member of staff due to maternity leave

and attempts to cover this post temporarily had been unsuccessful. The team felt that they were

stretched and had difficulties with the workload, however, the lead for complaints acknowledged

the support they received directly from the chief executive.

The trust board had delegated the governance arrangements for complaints to the quality

assurance committee. The complaints/compliments quarterly reports were provided to the

committee, the head of corporate affairs attended the relevant meetings to speak to the report.

The reports were also tabled at the service user safety group meetings where the head of

corporate affairs attended on a quarterly basis to speak to the report.

The trust website contained information on the complaints process and explained how people

could make complaints. It also provided contact numbers for those wanting more information.

There was a dedicated complaints inbox and complaints literature was available on all trust sites.

All complainants were offered the opportunity to meet with the chief executive to discuss their

complaint.

The complaints policy outlined actions, which should be taken if a complaint raised concerns with

regard to an adult at risk and possible physical, financial, psychological or any other kind of abuse.

However, it was identified at interview that if a complaint had not been received from an inpatient

area, then safeguarding concerns would not be routinely considered. This may lead to a

vulnerable person not receiving the appropriate safeguards.

We reviewed four complaints files and found that there was no standard format and no contents or

checklist to identify whether all actions had been completed. All but one of the complaints we

reviewed were acknowledged within the appropriate timescale, however one complaint, although

thoroughly investigated took over six months to complete. One complaint was acknowledged

seven days after receipt and put on hold. The complaint was withdrawn five months after it was

raised, however there was little information in the file to demonstrate what investigation had taken

place up to the time it was withdrawn. Completed complaints all had clear action plans with dates

for completion. Outcome letters were open and transparent with an apology provided to the

complainant appropriately.

This trust received 651 compliments during the last 12 months from 1 March 2017 to 28 February

2018. ‘Wards for older people with mental health problems’ had the highest number of

compliments with 34%, followed by ‘Community-based mental health services for adults of working

age’ with 23%.

Governance

The trust had a clearly defined operating, performance and governance structure that connected frontline clinical services with the board. The structure was refreshed and formally approved by the executive directors group in March 2018 following a clinical directorate restructure. The previous governance structures had not provided assurance regarding the quality and safety of services. The executive team now believed that the new governance systems and processes were more robust than those previously in place and these systems were currently being embedded across the trust but it was too early to assess with confidence how well this was working. On this inspection, it was clear that these systems were not yet embedded across front line services because the latest policies and procedures were not always being implemented. Policies had been ratified by the trust but had not been introduced on the forensic/low secure wards. In acute wards for adults of working age patients were not being monitored in line with trust policy following the administration of rapid tranquillisation.


There was a committee structure in place, with each committee chaired by a non-executive director with the appropriate skills and knowledge, reporting to the board. The committees were: • remuneration and nominations committee • audit committee • finance and investment committee • quality assurance committee • workforce, organisation and development committee. There was a reporting structure in place to manage the flow of information from directorate to executive management team and through to the board and relevant sub-committees. On a monthly basis, the director of operations provided a performance assurance report to the board that provided commentary to key exceptions, the plan to mitigate and timescale for update reporting to the board. This was supported via a performance dashboard derived from information reported by frontline teams. Clinical operations were represented on a variety of board sub-committees. Each directorate held monthly governance meetings in which wards and teams were represented. The service user safety group reported to the quality assurance committee and provided a forum for more detailed, deep dive discussions into particular thematic trends, the opportunity to share learning and practice and commission further work to support front line services. The structures and processes had not ensured that all breaches of Regulation identified at the last inspection had been addressed. In forensic wards work had not yet started to improve the seclusion room to meet the standard required in the Mental Health Act code of practice. Within the trust’s governance structure, there was a multi-disciplinary medicines optimisation committee, chaired by the chief pharmacist that reports to the service user safety group. The chief pharmacist is accountable to the medical director, and there was a clear line of sight to the Quality Assurance Committee at executive level. Medicines incidents were reviewed at a monthly medicines safety group meeting, however these were not always quorate as medical and risk department attendance was variable. The pharmacy service submitted a quarterly medicines safety report to the service user safety group. However, with the exception of reporting staff sickness, appraisal and compliance with mandatory training, there were no agreed performance measures to give assurance to the board about the performance of the pharmacy service. The pharmacy service outsourced their out of hours medicines supply to the local acute trust, however there was no formal contract or service level agreement in place to govern this relationship and ensure the quality of the service and performance of the contractor. Oversight of the Mental Health Act was provided through mental health legislation committee, the executive directors group and the quality assurance committee. There was an executive director Mental Health Act lead at board level through the director of nursing, but no non-executive director lead. The Mental Health legislation committee was a decision-making, monitoring and oversight sub-committee of the executive directors group, which met monthly. The committee monitored the use of the Mental Health Act in the trust, including key performance indicators and issues arising from the trust’s section 75 partnership with the local authority. It also received minutes from the associate hospital managers’ meetings. There were 19 associate hospital managers, which was sufficient for an organisation of its size, the ethnic mix was reflective of the area, and however, was not age representative as none were under the age of 55. There were robust systems in place in the Mental Health Act office, however these were in the process of being reviewed and formalised using a Microsystems approach.


The trust provided its Board assurance framework. This detailed any risk scoring five or higher and gaps in the risk controls that affect strategic ambitions. The trust outlined four strategic aims:

1 – Quality and safety 2 - People 3 – Future services 4 – Value for money

There were arrangements for identifying and managing the risks facing the organisation. The trust

had a board assurance framework that was used to inform the trust board agenda and was

populated utilising the trust’s risk management system. The Audit Committee identified papers

presented to board committees, which provided assurance against the strategic and delivery

objectives within the strategic planning framework 2017-2020. This evidenced mitigation of the

strategic risks contained within the board assurance framework including highlighting the board

assurance framework risks for which no reports had been received.

The board assurance framework was reviewed twice a year by the internal audit department and

significant work had been undertaken to improve the framework. The framework was split and

was discussed at the relevant committees with the complete board assurance framework reviewed

in each committee on a quarterly basis. Both the board assurance framework and the trust risk

register were discussed in the audit committee. This provided assurance to the board that risks

were being appropriately identified and managed.

The corporate risk register is a mechanism to manage high level risks facing the organisation from

a strategic, clinical and business risk perspective. The high level strategic risks identified in the

corporate risk register were underpinned and informed by risk registers overseen at the local

operational level within directorates.

The corporate risk register was presented to the executive directors group on a monthly basis for

the review of all risks. In addition, the group received details of escalated risks from directorate risk

registers on a monthly basis in order to determine their appropriateness for inclusion on the

corporate risk register. Relevant risks were also presented to board committees on a quarterly

basis. Board committees were required to ensure that papers presented provided sufficient

assurance that risks were being managed.

Key:

High (15-20) Moderate (8-15) Low 3-6 Very Low (0-2)

The trust has provided a document detailing their highest profile risks. Each of these have a risk

score of 15 or higher.

ID Risk Type Details Risk level

(residual)

Last review

date

3679 Safety Risk of harm to service users via ligatures 15 7 February

2018


Further high profile risks had been included on the register at the time of inspection. These related

to significant issues at the single point of access in relation to high call volumes thus resulting in

reputational damage and the inability to deliver timely triage and assessment at the single point of

access/crisis hub during times of higher demand.

Each team had its own risk register and staff in the organisation knew what the issues on their

team risk registers and how to escalate those risks to the directorate risk register. Team risk

registers were discussed in the monthly care network governance meetings. Pharmacy had a local

risk register in place, which was reviewed at monthly departmental meetings.

Risks were escalated to the directorate or corporate risk registers if they exceeded a set threshold.

We saw how risks had been escalated from team risk registers through to the corporate risk

register via the care networks risk registers. The risk to quality of care and patient safety during a

period of transition to the new model of service delivery for the adult recovery service throughout

2018 had also been added to the register. The risk was identified as moderate, but mitigation put

in place by the senior leadership team had not been effective in reducing risk. This had resulted in

a deterioration of the mental health crisis and health based places of safety core service, which we

found to be inadequate at this inspection.

Sheffield Health and Social Care NHS Foundation Trust has submitted details of five external reviews commenced or published in the last 12 months (1 March 2017 to 28 February 2018).

1. The trust was part of a pilot study by the Royal College of Psychiatrists regarding serious

incident investigations. An initial sharing event took place in October 2017, following which the Royal College of Psychiatrists published an occasional paper in March 2018 called 'Principles for full investigation of serious incidents involving patients under the care of mental health and intellectual disability provider organisations' which contains a set of principles for serious incident investigations.

2. On the 15 March 2018 the trust was a contributor to the Europides study into patient experience. Feedback has not yet been received.

3. CQC interviewed the trust as part of a case study regarding mental health trusts who had improved with regards to the CQC ratings. The trust’s rating had improved from 'requires improvement' to 'good'. The 'Driving Improvements' report has recently been published by the CQC.

4. The trust has been part of the CQC's whole system review in Sheffield relating to dementia care. Key outcomes are not yet known.

5. The trust participated in Healthwatch's review into the accessibility of services across different providers in Sheffield for people with hearing difficulties. Healthwatch's report has been published and the trust provided a response to Healthwatch. Recommendations made by Healthwatch relate to information on when and how to book British Sign Language interpreters, having information on complaints, concerns and advocacy being available in British Sign Language, communicating via two-way email and text messages and ensuring correspondence is written in an easy language.

Management of risk, issues and performance

Providers must report all serious incidents to the Strategic Executive Information System within

two working days of identifying an incident.


Between 1 March 2017 and 28 February 2018, the trust reported 29 Strategic Executive

Information System incidents. The most common type of incident was apparent/actual/suspected

self-inflicted harm with 18. Ten of these incidents occurred in community-based mental health

services for adults of working age services.

Never events are serious incidents that are entirely preventable as guidance, or safety

recommendations providing strong systematic protective barriers, are available at a national level,

and should have been implemented by all healthcare providers. Sheffield Health and Social Care

NHS Foundation Trust reported no never events during this reporting period.

We asked the trust to provide us with the number of serious incidents from the same period on their incident reporting system. The number of the most severe incidents was broadly comparable with the number the trust reported to Strategic Executive Information System.

Type of incident reported on STEIS

MH

Acu

te / P

ICU

MH

Co

mm

unity A

dults o

f W

ork

ing A

ge

MH

Co

mm

unity for

Old

er

Peop

le

MH

Crisis

HB

PO

S

Oth

er

MH

Substa

nce M

isuse

Oth

er

PM

S s

erv

ice

Unknow

n

Tota

l

Apparent/actual/suspected self-inflicted harm 2 10 1 3 1 1 18

Medication incident 3 1 1 5

Apparent/actual/suspected homicide 1 1 2

Abuse/alleged abuse of adult patient by staff 1 1

Disruptive/ aggressive/ violent behaviour 1 1

Pending review 1 1

Diagnostic incident including delay 1 1

Total 3 14 2 1 3 1 1 4 29

The trust had an incident management policy and procedure that identified the responsibilities of

staff at all levels in relation to serious incidents. The head of clinical governance managed serious

incidents. They were supported by the clinical risk manager and lead nurse for investigations.

Serious incidents were investigated by clinicians working in operational services; each

investigation was undertaken by two people, one of which was a consultant psychiatrist and the

other a senior clinician. Investigators were trained in root cause analysis investigation. The clinical

risk manager delivered training to new investigators.


During our inspection, we were informed that between nine and 12 months previously there had

been a backlog of serious incident reports due for submission to the clinical commissioning group.

The trust was breached for not meeting submission dates twice. At the factual accuracy stage the

trust submitted information to show that compliance for submission within the agreed timescales

was now at 84%. Clinicians involved in investigations negotiated the time with line managers;

however, it was acknowledged that clinicians were busy and it was not so easy to clear a

clinician’s diary in order to undertake investigations. The risk management team told us that they

supported operational services by stepping in to help clear the backlog, but could not demonstrate

any long-term plans to ensure that clinicians involved in investigations would be allocated

dedicated time to complete the investigation to meet agreed timescales.

The trust had systems in place to identify learning from incidents. The service user safety group

was responsible for ensuring that the incident management policy was effectively implemented

across the trust. The group had not ensured that all directorates had robust governance systems

in place to ensure that incidents were reported and that learning occurred at team and directorate

level. In wards for people with a learning disability and autism incidents were not reviewed quickly,

71 incidents had not been reviewed by the manager at the time of the inspection. This meant that

any learning from these incidents was not shared with staff in a timely way. Senior leaders and

managers described how learning was shared through directorate and team meetings. Staff

across the organisation told us of how they were provided with feedback following incidents within

their own teams.

However, governance systems and processes were not robust. Staff from a number of disciplines

and services reported that lessons learnt from incidents in other teams and services were not

routinely shared. This meant that safety issues which could have an impact across the trust may

not be addressed.

The Quality Assurance Committee was responsible for ensuring that incident management

processes were in place. The committee also requested assurance from the Service User Safety

Group that actions following serious incidents were effectively monitored and implemented. The

committee was also responsible for reporting on assurance to the trust board.

The local clinical commissioning group monitored the trust’s performance in the management of

serious incidents. This was completed through one to one meetings with the trust to review

progress against outstanding actions. An improvement was recognised in the trust’s timeliness in

submitting investigation reports. However, the timeliness of 72-hour reports and the trust’s

responsiveness to the commissioners’ comments following their review of reports remained an

issue.

Serious incidents were not always robustly investigated and reported. We reviewed five serious

incidents as part of our inspection and we found that two did not involve or liaise with other

agencies in the investigation, despite there being multi-agency involvement. We also found what

were described as root causes in the reports were often a list of the facts of the case rather than

an analysis of cause. Arrangements for shared learning were the same in each report reviewed,

with a standard statement that findings will be shared with teams directly involved and may be

shared with the wider directorate and that findings may be shared with the Service User Safety

Group.

The trust policy stated, service users, carers/families would be offered the opportunity to be

involved, and that where they did not wish to be involved in the actual investigation, once the

report and action plan were completed, they would be contacted again to advise them of the report

completion and to ascertain how they would like to receive feedback on the findings and a copy of


the finalised report would be shared, or discussed, with them, where this was requested. We only

found evidence of patient or family involvement in two reports and in one case the final term of

reference stated that patient would be given opportunity to be involved in the investigation. There

was evidence of a letter being sent but no evidence of any further correspondence with patient or

family. In another report it was unclear whether conclusions were shared with the patient, even

though the original letter prior to investigation stated that this would happen. This was not

discussed within the report and there was no evidence of further communication with patient. Two

of the cases reviewed showed that the trust’s policy for duty of candour had not been followed.

Copies of serious incident action plans were not always maintained contemporaneously to reflect

the actions undertaken by the trust. We found that action plans in one of the reports were not

signed as completed within the timescale. However, we looked at this incident within the relevant

core service and found that staff were aware of the learning and the actions were complete. This

raised concerns that systems to support information reporting by the clinical governance and risk

management team may not be robust.

Safeguarding adults and children sat within the portfolio of the director of nursing, professions and

care standards. There was a lead doctor for safeguarding in place. There had been a complete

change of personnel within the safeguarding team within the last two years, the team now had a

safeguarding lead for adults and children from a social work background and a safeguarding

advisor with a nursing background; the team were supported by an administrator.

The annual work plans were linked to Safeguarding Children / Adult Boards priorities in the local

authority, the clinical commissioning group and police priorities. Quarterly meetings were attended

by the executive nurse or deputy chief nurse to this external board. The lead professionals

supported the functions of the local safeguarding children boards and safeguarding adult boards

by attending and contributing to the subgroups and the broader activities of those boards. This

included audit activity, serious case reviews and safeguarding adults’ referrals.

Safeguarding adults and children was reported quarterly to the quality assurance committee in the

trust by the deputy chief nurse. The trust had children and adults steering groups chaired by the

deputy chief nurse to ensure communication with clinical commissioning group, local authority and

safeguarding managers. This ensured joint work plans were progressing. The safeguarding team

attended and met with senior operational managers and safeguarding managers through different

routes. This included multi-disciplinary meetings, governance meetings and group or 1:1

supervision as well as being involved in complex case reviews. The mental health crisis service

and health based places of safety and the community based mental health services for adults of

working age had trained safeguarding managers who were responsible for overseeing the

safeguarding adults processes and outcomes within the team.

The safeguarding team were enthusiastic and knowledgeable and had a clear vision, they

believed that safeguarding should be city wide to enable early identification of at risk city areas

and so that intelligence could be gathered and safeguarding implemented sooner rather than later.

It was acknowledged that this was a challenge. However, an example of joint working included a

monthly city centre anti-social behaviour meeting, in which individuals at risk across the city were

discussed. An example of this had shown that this meeting had resulted in a referral to the trust’s

services and a plan for engagement to improve the individual’s mental health and circumstances;

a man who lived in extremely poor conditions and who had some evidence of mental illness led to

a referral to the trusts single point of access team. Some five months later the team continued to

have an active plan to engage with the man.


The safeguarding team felt that the accountable care partnership enabled and supported joint

working. They had begun a piece of work with the local authority to develop an integrated city wide

performance report and communication. This was also to involve information from the local police

service.

Mandatory safeguarding training rates had a marked increase since our last inspection. The

safeguarding training package had been reviewed in the past year and updated to reflect new

emerging themes such as human trafficking, self-neglect, domestic abuse, female genital

mutilation and Prevent items. The team told us that safeguarding referrals had increased by 40

percent over the past year, with a significant increase in notifications of self-neglect.

Providers are encouraged to report patient safety incidents to the National Reporting and Learning

System at least once a month. They do not report staff incidents, health and safety incidents or

security incidents to National Reporting Learning System.

The highest reporting categories of incidents reported to the National Reporting Learning System

for this trust for the period 1 March 2017 to 28 February 2018 were patient accident, disruptive,

aggressive behaviour (includes patient-to-patient) and self-harming behaviour. These three

categories accounted for 2839 of the 4351 incidents reported. Self-harming behaviour accounted

for 24 of the 30 deaths reported.

Seventy eight percent of the total incidents reported were classed as no harm and 17% were

classed as low harm.

Incident type No harm Low harm Moderate Severe Death Total

Patient accident 1099 83 14 2 0 1198

Disruptive, aggressive

behaviour (includes patient-to-

patient)

944 148 33 1 0 1126

Self-harming behaviour 343 136 10 2 24 515

Medication 343 61 7 2 1 414

Access, admission, transfer,

discharge (including missing

patient)

88 131 53 0 0 272

Other 224 36 3 0 5 268

Treatment, procedure 146 45 7 1 0 199

Infrastructure (including staffing,

facilities, environment) 104 67 18 0 0 189

Implementation of care and

ongoing monitoring / review 10 22 10 0 0 42

Patient abuse (by staff / third

party) 32 4 4 0 0 40

Clinical assessment (including

diagnosis, scans, tests,

assessments)

19 12 4 1 0 36

Consent, communication,

confidentiality 19 2 3 0 0 24

Documentation (including

electronic & paper records, 9 3 1 0 0 13


Incident type No harm Low harm Moderate Severe Death Total

identification and drug charts)

Medical device / equipment 8 1 0 0 0 9

Infection Control Incident 3 3 0 0 0 6

Total 3391 754 167 9 30 4351

Organisations that report more incidents usually have a better and more effective safety culture than trusts that report fewer incidents. A trust performing well would report a greater number of incidents over time but fewer of them would be higher severity incidents (those involving moderate or severe harm or death). Sheffield Health and Social Care NHS Foundation Trust reported more incidents from 1 March 2017 to 28 February 2018 compared with the previous 12 months.

Level of harm 1 March 2016 to 28 February

2017

1 March 2017 to 28 February

2018

No harm 3211 3391

Low 609 754

Moderate 125 167

Severe 8 9

Death 24 30

Total incidents 3977 4351

Staff were encouraged and knew how to report incidents on the trust’s incident management

system. All medicines incidents were reviewed by the acting Medicines Safety Officer.

Information Management

Leaders in the trust undertook the necessary information management roles. These included leaders allocated to be the Caldicott Guardian, Senior Information Risk Owner, Chief Clinical Information Officer and a Clinical Safety Officer. The trust also had a director of Information Management, Systems and Technology who was a chief information officer. The trust had ensured that the appropriate actions were taken in line with the General Data Protection Regulation introduction.

The trust’s information management systems were fit for purpose and provided the technical capability and infrastructure required at the time. The information systems in place were initially built by the trust 15 years previously. These had been maintained with additional capabilities and developments added on as required. The trust had identified that significant digital developments were required as the system was underpinned by dated technology and software and there had been some unplanned power outages, which could pose significant risks to performance and safety.

The trust had systems and processes to mitigate and manage potential risks to information management and information technology systems within the trust. This included the cyber threats and security breaches. Examples of these included: regular user and administrator password changes and the trust also sent out some pseudo phishing emails sent to staff. If staff responded to these, they provided education on security and risks. The trust also ensured that they received and acted upon communication from NHS Digital’s Care Computer Emergency Response Team.


The team send external alerts to trusts and provided co-ordinated responses to try and deal with cyber security threats. The trust reported no cyber security incidents to date.

The trust had effective information governance arrangements in place. These included a data information governance board and a digital transformation board that oversaw the systems and processes around information management and the future digital strategy.

At the time of our inspection, the strategic outline case for digital integrated mental health care programme was in the process of going to board for approval. The trust had developed strong working links with local systems partnerships and digital programmes at a national level. In particular, the trust had been selected by NHS Digital to participate in a collaborative partnership with another trust in the NHS Mental Health Global Digital Exemplar Programme. This programme matched trust financial investment and is aimed at identifying digital systems and models that are effective and can be used more widely across NHS services. The strategic case had been through the appropriate governance processes prior to being discussed at board and had involved operational staff working in and managing frontline services. The board had requested further capacity impact consideration on operational staff prior to a decision being made.

Engagement

The trust held an annual members’ meeting, which provided an opportunity for members and the public to learn more about the trust, its services and to ask questions. Monthly open board of directors’ meetings were held and the papers and agendas for those meetings were published on the trust’s website. The website and other social media channels were used to engage with the public. Patients and carers were members of the service governance structures and actively participated in groups to contribute to planning and service improvement such as the inpatient forum, Service User Safety Group and restrictive interventions project group.

The main service user network (SUN:RISE) met monthly and followed a formal business agenda, but also had guest speakers invited which had included regular presentations on the planned changes to adult community mental health services. SUN:RAYS and SUN:LITES groups addressed topics, which were relevant to individual services.

The service user engagement group members held bi-monthly roadshows at varying sites across the trust, to collect both patient and staff views on improving service user experience. A particular emphasis was placed on working with and learning from harder to reach groups and external organisations such as: The Alzheimer’s Society, and the Sheffield African Caribbean Mental Health Association.

The trust had a council of governors that included publicly elected governors, elected staff governors and governors appointed to represent organisations regarded as the trust’s stakeholders or partners. They were provided with training on their appointment and had access to ‘govern well training’ and training in information technology was also available if required. The trust did not provide any ongoing training, but it was acknowledged they should.

Governors and staff participated in a number of community events, such as the Wellbeing Festival and Sheffield Mental Health Week to recruit and engage members from across the city. However, some governors we spoke with told us that support for attendance at these events had reduced. Feedback from the governors regarding engagement with the trust was mixed; some governors felt they were unable to challenge the non-executive directors as their questions were nearly always answered by executive directors. They also felt that the agenda for their meetings did not always include items they had requested. Whereas, others felt the trust provided opportunities to engage with meetings and committees.

Governors said they were well supported by the deputy board secretary and some spoke about an open culture among the trust board. However, some governors said they felt that they were not as engaged as they had been previously and that it was difficult to get answers to questions raised. Both the chief executive and the chair recognised that the relationship with some governors had


deteriorated in recent months and had identified issues, which needed to be resolved to ensure the council of governors was able to fulfil its obligations.

The work of service users in the Reducing Restrictive Practice Group had been instrumental in the trust leading the way nationally in eliminating the use of face down restraint on in-patient wards. Figures released by NHS Benchmarking, showed that the trust had the lowest level of face-down restraint across England and Wales, and year on year the use of face-down (prone) restraint in the trust had reduced. In the past eighteen months there had been no use of face down restraint in the trust.

The trust was engaged with a number of partner organisations in order to develop and improve the service provided to its population. These included but were not limited to:

• A formal partnership agreement between the trust and Primary Care Sheffield to enable them to deliver effective primary medical services within general practices across Sheffield. Engagement and feedback took place via a joint executive board between the two organisations. An example of successful joint working was system wide work on the Older People's Pathway. This was a collaborative referral pathway located on the GP press portal for every GP in the city.

• The trust had a contract with Sheffield Flourish to support service users on their recovery journey. Projects included the Oasis garden project, which supported people into training and work, and the Brunsmeer Football programme, which addressed physical wellbeing and challenging stigma through football. Engagement and feedback with service users was built into the design of the projects.

• The trust had a range of contracts and partnership projects with South Yorkshire Housing Association, including a dementia care home, and the joint delivery of community enhanced recovery support with South Yorkshire Housing Association’s Living Well Team. This team aims to meet the needs of people with severe mental health problems returning to Sheffield from out of area placements to their own tenancies.

• The trust worked jointly with Rethink to establish a crisis house as an integral part of the acute care pathway.

The trust was an outward facing organisation, we saw how planning and decision-making was conducted not only for the benefit of the trusts current patient population, but also considered how they might benefit the whole population of the city of Sheffield. The trust had a strong position in the integrated care system and the chair described how a third of her time was spent working with stakeholders, which included membership of the accountable care partnership oversight and assurance group, the integrated care system governance sub group and health and wellbeing board. Other members of the executive team, including the chief executive and the director of human resources had roles within the integrated care system and accountable care partnership.

The trust had a good a working relationship with the local clinical commissioning group and although there had been previous difficulties, the relationship with the local authority was now described as good by the chief executive. This view was supported in feedback from the local authority who told us that senior managers were outward looking, innovative and open to new ways of working to meet the needs of stakeholders.

The trust had worked collaboratively with the local clinical commissioning group to improve and develop services to meet the needs of its patients and the Sheffield population in line with Mental Health Five Year Forward View. To support strategic planning and the implementation of transformation a tripartite arrangement had been developed to progress changes through a clear programme of work. A senior programme post was jointly funded between the trust, the clinical commissioning group and the local authority with significant progress being made with a joint memorandum of agreement and financial risk share being developed.


There were service level agreements and memorandum of understanding with the local acute trust and children’s hospital trust to provide support over Mental Health Act documentation and provide advice. Multi-agency policies and protocols were in place for Mental Health Act issues and a multi-agency place of safety protocol had been developed.

Learning, continuous improvement and innovation

The executive lead for research and clinical audit was the medical director and they were supported by a director of research and development. A research champions network that met regularly with the director had been set up to promote research across the trust.

The trust worked closely with the Yorkshire and Humber Collaboration for Leadership in Applied Health Research and the Yorkshire and Humber Local Research Network and had strong links with academic partners, including the two universities in Sheffield.

The trust was involved in a research project with a local university entitled ‘Journeying through Dementia’. This was a research project where people with dementia worked alongside researchers to co-create a self-management programme for people with dementia.

The trust used the Join Dementia Research tool designed by the National Institute for Health Research in association with Alzheimer’s Research UK and the Alzheimer’s Society to match service users who have expressed an interest in research with appropriate studies.

At the end of 2017/18 there were 39 active clinical research projects underway in the trust; these included:

• A randomised controlled trial of an intervention to reduce or prevent weight gain in severe mental illness.

• A trial comparing the effectiveness of counselling for depression with cognitive behavioural therapy.

• A multi-centre trial of a self-help intervention to improve quality of life in Alzheimer’s disease.

• Support for the families and carers of service users with dementia.

• Interventions for service users with eating disorders.

• The effectiveness of services for mothers with mental illness.

• Co-morbidities between physical health and mental health.

• Pharmaceutical trials of new drugs for service users with dementia (including Alzheimer’s disease).

During 2017/18 the trust were involved five national clinical audits and four national confidential enquiries, these were as follows:

• Mental Health Clinical Outcome Review Programme

o Suicide in children and young people

o Suicide, homicide and sudden unexplained death

o The management and risk of patients with personality disorder prior to suicide and homicide


• Learning Disability Mortality Review Programme (LeDeR Programme)

• National Core Diabetes Audit

• National Audit of Early Intervention Services

The trust participated in benchmarking audit through POMH-UK (Prescribing Observatory for Mental Health UK), these included:

• POMH Topic 17: Use of depot/long acting antipsychotics for relapse prevention

• POMH Topic 15: Prescribing valproate for bipolar disorder

Actions were developed following a high dose and combination antipsychotics audit to reduce the use of high dose and combinations, particularly on the acute mental health wards. The audit also identified an increase in the use of a single antipsychotic on forensic wards, but relatively high use of high dose and an increase in combination antipsychotics prescribed on the rehabilitation wards. Work was planned with rehabilitation wards to link monthly monitoring to multi-disciplinary reviews and team governance.

The trust conducted a range of local clinical audits, including an audit of physical investigations for admitted psychiatric patients, which led to an increased awareness of the physical health investigations standard operating procedure. Physical health monitoring in the early intervention service led to the services microsystems team leading the development of changes in team practice to drive the necessary improvements.

Wards and teams also undertook audits locally and we saw actions to improve following audits within clinical areas.

The Transforming Acute Care Programme implemented a new model of in-patient care for mental health service users with the result that far fewer Sheffield residents were being sent out of city for treatment and care. This was highly commended in the National Positive Practice Awards. The quality improvement team, which included an expert by experience who was appointed as an improvement coach to enhance the concept of co-production with service users and carers in all quality improvement activity, was highly commended in the quality improvement category. This reflected the quality improvement work supported by the microsystem improvement methodology that is championed across the trust.

Microsystem improvement involves engaging members from individual teams (the microsystem) to work collectively as an interdisciplinary group to improve the quality of care for patients as well as the workplace for staff who work there. A trained microsystem coach facilitated teams, through a structured improvement process, engaging and empowering front line staff, patients and carers to design and influence change from the front-line. At the time of our inspection there were 15 service users and family members who regularly participated in microsystems meetings. There were 35 members of staff who had been trained as a microsystem coach by the Sheffield Microsystem Coaching Academy, with 43 teams having used the approach to implement quality improvements.

Improvement stories and good practice were shared through internal directorate governance structures, the trusts intranet, the Sheffield Microsystem Coaching Academy website, local and national conferences and award ceremonies.

The trust holds an annual quality improvement event where staff and service users are invited to take part. Examples of influencing improvements include:

• Short Term Education Programme - three service users contributed to changes aiming to improve attendance rates and are subsequently involved in the review.


• Intermediate Care Beds introduced a workbook to promote patient activation to their well-being.

• The Sheffield Community Brain Injury Rehabilitation Team identified a feedback station in their waiting area as a result of service user suggestion.

Other initiatives included leadership development workshops, and leadership engagement network events where the chief executive met with frontline leaders to converse, listen and interact on a direct level.

Historical data Projections

Financial Metrics Previous financial

year (2 years ago)

Last financial year

(2017)

This financial year Next financial year

(2019)

Income £128.216m £121.170m £120.371m £115.025m

Surplus (£0.139m) £1.529m £4.576m £1.502m

Full costs (£128.605m) (£122.580m) (£115.769m) (£113.630m)

Budget £1.234m £0.970m £1.529m £1.502m

NHS trusts can take part in accreditation schemes that recognise services’ compliance with standards of best practice. Accreditation usually lasts for a fixed time, after which the service must be reviewed.

The table below shows services across the trust awarded an accreditation (trust-wide only) and the relevant dates.

Accreditation scheme Core service Service accredited Comments and Date of accreditation /

review

AIMS - Rehab (Rehabilitation

wards)

Long stay /

rehabilitation

mental health

wards for working

age adults

Forest Close

At peer inspection stage

Quality Network for Perinatal

Mental Health Services

(QNPMH)

n/a Perinatal Mental

Health Services

At peer inspection stage

ECT Accreditation Scheme

(ECTAS)

n/a ECT Suite

September 2016 - 2019

Psychiatric Liaison

Accreditation Network (PLAN)

n/a Liaison Psychiatry

21st March 2017- 2020

Memory Services National

Accreditation Programme

(MSNAP)

n/a Sheffield Memory

Service

July 2015 - 2018. Accredited since

2010. Most recent reaccreditation

2017

Royal College of Psychiatry -

Home Treatment Accreditation

Standards (HTAS)

Specialist

community mental

health services for

adults

South West Home

Treatment Team

Accredited December 2016 - 2019


The trust had a learning from deaths policy, which outlined staffs’ roles and responsibilities relating

to learning from deaths and promoted a culture of learning. Systems were in place to identify and

learn from all deaths, including unanticipated deaths. The trust was part of Northern Alliance (an

alliance of mental health trusts in Yorkshire, Cumbria and the North East) which formed following

the published outcome of the Mazars’ report into all deaths of service users who received mental

health or learning disability services at Southern Health NHS Foundation Trust in order to develop

a common approach to mortality across the region. Mortality was reviewed using information

reported through the trusts incident management system as well as deaths recorded through the

national death reporting mechanisms.

The trust had an established Mortality Review Group, which was chaired by the medical director,

and had robust systems in place to review all deaths of patients with mental health problems or a

learning disability against set criteria in line with the trust’s policy. The group met weekly and

considered all deaths that had been recorded as an incident on the trust’s risk management

system, together with sampling a number of deaths not recorded as an incident, but whose death

has been recorded through national death reporting processes. Each death was considered to

ascertain if sufficient information was known about the care provided leading up to the person’s

death, to enable the group to be satisfied and assured. Each case was closed only when the

mortality review group were satisfied with the response to the review and were assured that

contact with families had taken place to enable them to identify any concerns. Unexpected deaths

could also be subject to further review using the Structured Judgement Framework tools.

Structured judgement review methodology is used in practice within a large NHS region. It is

based upon the principle that trained clinicians use explicit statements to comment on the quality

of healthcare in a way that allows a judgement to be made that is reproducible. Unexpected

deaths, not thought to be from natural causes, may be subject to a review of care in line with the

trusts serious incident policy which may lead to a further investigation using root cause analysis

techniques.

The trust also participated in the Learning Disabilities Mortality Review programme, commissioned

by NHS England to ensure that the reviews of deaths lead to learning and improvement in

services for people with learning disabilities. The trust had reported eight deaths to the Learning

Disabilities Mortality Review programme during quarter 4 2017/18, but at the time of inspection

had not received any findings or lessons learned.

As required by NHS England national quality board the trust report their mortality to a public board

meeting on a quarterly basis through a mortality review paper produced by the mortality review

group and monthly via the safety dashboard, a tool developed by the Northern Alliance, which

recorded learning points arising from serious incident investigations that will potentially result in

changes in practice.

The trust were instrumental in developing the Sheffield case register to ensure that notification

was received regarding the death of any person with a learning disability in the city. The need was

identified due to the number of people with a learning disability accessing the local acute hospitals

trust who were not necessarily in contact with services at Sheffield Health and Social Care NHS

Foundation Trust. The register is now used city wide by organisations providing services to people

with a learning disability to record deaths and facilitate learning, which would otherwise not have

been shared. We saw an example of how an issue with posture management led to the

amendment of the assessment following a citywide audit of practice. Speech and language

therapists and physiotherapists are now working together, to use the same assessment tool.


Mental health services Forensic inpatient/secure wards

Facts and data about this service

Sheffield Health and Social Care NHS Foundation Trust has two low secure forensic mental health inpatient wards. Each ward provides care and treatment for up to 11 patients. All the patients who receive care on these wards are detained under the Mental Health Act 1983. Forensic inpatient wards are located at Forest Lodge and are separated into assessment and rehabilitation wards.

Location site name Ward name Number of beds Patient group (male,

female, mixed)

Forest Lodge Assessment

Ward 11 Male

Forest Lodge Rehabilitation

Ward 11 Male


Is the service safe?

Safe and clean care environments

Safety of the ward layout

Staff carried out regular risk assessments of the care environments. During a previous inspection a number of ligature risks had been highlighted. None of the wards presented a high level of ligature risk and both wards presented a lower risk due to the acuity of service users and remaining anchor points. The trust had identified the remaining ligature risks and renovation work was being carried out to further reduce these.

There were ligature risks on both wards within this core service. The trust had undertaken recent (from 1 April 2017 onwards) ligature risk assessments at one location. None of the wards had not had a ligature risk assessment in the last 12 months.

The trust had taken the following actions to mitigate ligature risks: Risk management of service users includes risk assessment, observations levels, and removal of items that may be used.

During our inspection, work was underway to replace all the doors in the service to ensure they did not provide anchor points. All doors were being replaced with anti-barricade doors and handles were anti-ligature alternatives. All bathrooms within the service had been renovated and replaced with anti-ligature fixtures. A ligature risk or a ligature point is anything which items could be secured onto for the purpose of strangulation or hanging.

Both wards were laid out in a way that prevented staff from observing all areas of the ward at all times. Neither ward had closed circuit television or mirrors to assist staff to see areas that were out of view. In order to reduce the risks on the assessment ward, a member of staff was assigned to observe the corridors.

The wards complied with eliminating mixed-sex accommodation. Over the 12-month period from 1 March 2017 to 28 February 2018 there were no mixed sex accommodation breaches within this core service.

Staff had easy access to alarms. Staff working on the wards were issued with personal infrared transmitter alarms and keys when they arrived. Alarms and keys were attached to a belt at all times which helped to ensure they would not get misplaced.

Patients did not have access to nurse call systems. None of the rooms within the service were fitted with nurse call systems and patients were not provided with any form of hand-held system. This meant that patients couldn’t summon help if they needed it.

Maintenance, cleanliness and infection control

All areas were clean, had good furnishings and were well maintained. The trust employed housekeeping staff to carry out cleaning activities on both wards. A cleaning schedule was in place for each ward which showed cleaning for the service was carried out in accordance with the schedule.

The most recent patient-led assessments of the care environment assessment was carried out in 2017. Forest Lodge scored higher than the similar trusts for all three of the applicable aspects overall. The scores achieved are shown in the table below:

Site name Core service(s)

provided

Cleanliness Condition

appearance

and

maintenance

Dementia

friendly

Disability

Forest Lodge MH - Forensic 99.5% 97.3% - 92.1%



provided


appearance

and

maintenance

Dementia

friendly

Disability

inpatient

Trust overall 99.0% 97.8% 91.1% 91.8%

England average (Mental

health and learning

disabilities)

98.0% 95.2% 84.8% 86.3%

Staff adhered to infection control principles. There were adequate places for staff to wash their hands and alcohol hand gel was also available.

Seclusion room

The seclusion room did not comply with the requirements set out in the Mental Health Act code of practice. In our previous inspection of the service we identified that the seclusion room was not in accordance with the Mental Health Act code of practice as staff would not be able to see patients if they were to close the door to the toilet area. In order to mitigate the risk, the door to the toilet area was now left open at all times.

During this inspection we found that the door on the seclusion room toilet was now left open at all times and staff were required to watch patients throughout the time in the toilet. This was to prevent patients from harming themselves while using the facilities. However, we were concerned that this meant patient privacy and dignity was not protected.

The trust was made aware of our concerns at the time of the last inspection and a plan was put in place to have the seclusion room renovated. The trust was granted funding to have this work carried out the week before our inspection and it has now been agreed that work can commence in November 2018.

There was a seclusion mattress in place and patients were able to see a clock for orientation to time. There was two-way intercom in place however, communications were not clear and staff told us it was often difficult to hear what was being said.

Staff were positioned outside the seclusion room for the time it was in use, observing patients and carrying out physical health observations. Staff were able to see patients from a sitting or standing position with the use of mirrors through the observation hatch. Patients had access to a toilet and washing facilities in a room adjacent to the sleeping area.

Clinic room and equipment

Wards had access to resuscitation equipment and emergency drugs. Each ward had a clinic room which contained emergency bags and the equipment required by the Resuscitation Council for use in an emergency. Staff checked equipment regularly to ensure they were ready for use if required.

Clinic rooms did not always have sufficient space. The clinic room on the assessment ward was very small and there was no room for an examination couch. Staff had access to equipment to carry out physical health observations however examinations had to be carried out in patient bedrooms. We spoke with the ward manager about this and were told there had been no incidents because of this practice.

The clinic room on the rehabilitation ward was new and although a couch had been ordered this was not in place at the time of our inspection. All the medical equipment in the clinic rooms was clean, in date and calibration of equipment had been carried out.

Staff checked the temperatures in clinic rooms and medication fridges. Temperatures in clinic rooms were controlled with the use of air conditioning ensuring they were kept within the recommended ranges for the storage of medicines.


Safe staffing

Nursing staff

The trust provided information on key staffing indicators. The table below shows information

submitted:

Definition






5.2 N/A


9% 13%


Total vacancies overall (excluding seconded staff) At 31March 2018 13 N/A

Total vacancies overall (%) At 31March 2018 20% N/A



6% 5%


5% 5%


Establishment levels qualified nurses (WTE*) At 31 March 2018 22 N/A

Establishment levels nursing assistants (WTE*) At 31 March 2018 29 N/A

Number of vacancies, qualified nurses (WTE*) At 31 March 2018 1 N/A

Number of vacancies nursing assistants (WTE*) At 31 March 2018 11 N/A

Qualified nurse vacancy rate At 31 March 2018 5% N/A

Nursing assistant vacancy rate At 31 March 2018 38% N/A

Bank and agency Use


(qualified nurses) 1 March 2017 and 28

February 2018 455 (12%) N/A


(Qualified Nurses)

1 March 2017 and 28

February 2018 72 (2%) N/A


absence or vacancies (Qualified Nurses)

1 March 2017 and 28



(Nursing Assistants)

1 March 2017 and 28

February 2018 3008 (51%) N/A



1 March 2017 and 28

February 2018 160 (<1%) N/A


absence or vacancies (Nursing Assistants)

1 March 2017 and 28

February 2018 186 (<1%) N/A



This core service reported an overall vacancy rate of 5% for registered nurses at 31 March 2018.

The vacancy rate for registered nurses was higher than the 0% reported at the last inspection.

This core service reported an overall vacancy rate of 38% for nursing assistants.

The vacancy rate for nursing assistants was higher than the 16% reported at the last inspection.

This core service has reported a vacancy rate for all staff of 20% as of 31 March 2018. This was higher than the rate (14%) reported at the last inspection (between 1 August 2016 and 31 July 2017).

Registered nurses Health care assistants Overall staff figures

Ward/Tea

m

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Forest

Lodge 1 22 5% 11 29 38% 13 65 20%

Core

service

total

1 22 5% 11 29 38% 13 65 20%

Trust

total 32 433 7% 15 353 4% 68 1339 5%

NB: All figures displayed are whole-time equivalents

The trust submitted data regarding covering shifts for registered nurses. This showed that between 1 November 2016 and 31 October 2017, that bank staff filled 10% and agency staff filled 3% of shifts to cover sickness, absence or vacancy for registered nurses.

Two percent of shifts were unable to be filled by either bank or agency staff.

Between 1 March 2017 and 28 February 2018, bank staff filled 12% of shifts to cover sickness, absence or vacancy for qualified nurses.

In the same period, agency staff covered 2% of shifts for qualified nurses. Five percent of shifts were unable to be filled by either bank or agency staff.

The table below shows the number of registered nurse shifts filled by bank and agency staff and the number of shifts which were not filled:

Ward/Team Available shifts Shifts filled by bank

staff

Shifts filled by

agency staff

Shifts NOT filled by

bank or agency staff

Assessment

Ward 1939 170 (9%) 16 (1%) 126 (6%)

Rehabilitation

Ward 1719 285 (17%) 56 (3%) 60 (3%)

Core service

total 3658 455 (12%) 72 (2%) 186 (5%)

Trust Total 32,394

4977

(15%)

7252

(22%)

900

(3%)

*Percentage of total shifts

Between 1 March 2017 and 28 February 2018, 51% of shifts were filled by bank staff to cover sickness, absence or vacancy for nursing assistants.

In the same period, agency staff covered 9% of shifts. Three percent of shifts were unable to be filled by either bank or agency staff.



staff

Shifts filled by

agency staff

Shifts NOT filled by bank

or agency staff

Assessment

Ward 3607 2048 (57%) 145 (4%) 20 (1%)

Rehabilitation

Ward 2305 960 (42%) 15 (1%) 60 (3%)

Core service

total 5912 3008 (51%) 160 (3%) 80 (2%)

Trust Total 59,514

21,770

(37%)

5623

(9%)

1760

(3%)

* Percentage of total shifts

The trust provided information on staff turnover rates. This core service had 5.2 (9%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 14% reported at the last inspection (between 1 August 2016 and 31 July 2017). This core service had 42 (equal to the average of 13%) staff leavers between 1 November 2016 and 31 October 2017.

Ward/Team Substantive staff

Substantive staff Leavers Average % staff leavers

Forest Lodge 53.8 5.2 9%

Core service total 53.8 5.2 9%

Trust Total 1351.6 129.6 8%

The annual sickness rate for this core service was 5% between 1 February 2017 and 31 January 2018.

The sickness rate for this core service was 7% between 1 November 2016 and 31 October 2017. The most recent month’s data submitted by the trust [October 2017] showed a sickness rate of 8%.

Sickness rates for this core service ranged between 6% in June 2017 and 9% in January 2017. The table below shows sickness rates for this core service:

Ward/Team Total % staff sickness

(at latest month)

Ave % permanent staff sickness

(over the past year)

Forest Lodge 6% 5%

Core service total 6% 5%

Trust Total 8% 7%

The below table covers staff fill rates for registered nurses and care staff between November and February 2018. The fill rates for the rehab ward were under 90% for care staff during day shifts in December 2017 and February 2018.


> 125% < 90%

N – Nurse

C- care staff

The shift patterns for the service were;

• Early shift – 7am to 3pm

• Late shift – 1.30pm to 9.30pm

• Night shift – 9pm to 7.30am

Staffing levels were sufficient to meet the needs of patients. Staffing levels were worked out using a combination of professional judgement and workload calculations based on the Keith Hurst Tool and National Quality Boards.

During the day, there were two registered nurses and three health care support workers on the assessment ward and two registered nurses and two health care support workers on the rehabilitation ward. During the night, the assessment ward had one registered nurse and three health care support workers and the rehabilitation ward had one registered nurse and one health care support worker.

The ward manager told us that she was able to adjust the staffing levels according to the needs of the patients. However, the renovation work that had been carried out had also resulted in the need for additional staff during the day.

Although managers could increase staff numbers the trust reported that they had not been able to fill all shifts with bank and agency staff. Information provided showed that 186 (5%) shifts for registered nurses and 80 (2%) for health care support workers between 1 March 2017 and 28 February 2018 were not filled.

Wards had sufficient staff to carry out physical interventions. Forest Lodge operated a response system which ensured that were staff could get assistance quickly when needed. Staff told us that they were given help when needed however, some staff felt this could cause problems as it may leave the ward short staffed while they dealt with the incident.

Medical staff

There was adequate medical cover during the day and a doctor could attend the ward quickly in an emergency. We asked the trust for information regarding medical cover; however, medical locum information was not provided for this service. The trust informed us that this was because a locum had not been required at the service in the previous twelve months. The service had two consultants who equalled 1.7 whole time equivalent staff and a staff grade doctor who were on duty during the day.

During out of hours there was an on-call system in operation. Staff told us that there were occasional issues getting support from doctors as there was only one consultant to cover services throughout the Sheffield area. The trust told us that doctors were not expected to attend the ward

Day Night Day Night Day Night Day Night

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

November 2017 December 2017 January 2018 February 2018 Assessment 118.

1

97.9 106

.

105.

9

103.

5

99.

6

98.

9

100.

1

102.

8

108.

2

102.

5

103.

0

108.

4

91.

1

101.

8

102.

7

Rehabilitatio

n

96.9 100.

5

93.

3

108.

0

111.

0

86.

0

96.

8

102.

9

104.

0

95.1 96.8 97.7 101.

6

86.

3

107.

5

100


and they were able to deal with some enquiries via telephone, although they did attend the ward to carry out seclusion reviews when required.

Mandatory training

The compliance for mandatory and statutory training courses at 28 February 2018 was 92%. Of the training courses listed one failed to achieve the trust target.

The training compliance reported for this core service during this inspection was higher than the 61% reported at the last inspection.

The table below shows the mandatory training compliance rates for this core service:

Key:

Below CQC 75% Between 75% & trust

target Trust target and above

Training course This core service %

Trust target % Trustwide mandatory/ statutory training total %

Safeguarding Children (Level 2) 100% 80% 85%

Clinical Risk Assessment 100% 80% 91%

Equality and Diversity 98% 80% 95%

Fire Safety 2 years 98% 80% 96%

Hand Hygiene 98% 80% 94%

Health and Safety (Slips, Trips and

Falls) 98% 80% 97%

Safeguarding Adults (Level 2) 98% 80% 87%

Mental Capacity Act Level 1 97% 80% 94%


Respect Level 2 93% 80% 80%

Domestic Abuse Level 2 92% 80% 85%

Dementia Awareness (inc Privacy &

Dignity standards) 91% 80% 85%

Autism Awareness 90% 80% 88%


Mental Health Act 88% 80% 83%

Medicine management training 87% 80% 87%

Immediate Life Support 85% 80% 88%

Adult Basic Life Support 84% 80% 81%

Information Governance 83% 80% 80%

Rapid Tranquilisation 81% 80% 88%


Core Service Total % 92% 80% 88%

Assessing and managing risk to patients and staff

Assessment of patient risk

Staff completed an assessment of patient risk when they arrived on the ward. The core service used the historical clinical risk management 20 tool. This is a recognised risk assessment tool which is primarily used to assess the risk of violence and aggression.

We looked at eight patient care records and found six of these had an up to date risk assessment and these had also been regularly updated. Although the other two records had a risk assessment in place, these were not up to date.


Other parts of these patients care records contained information in relation to identified risks. Staff that we spoke to had detailed knowledge of individual patients and risk.

Management of patient risk

Staff identified and addressed specific risk issues. Records contained evidence that when required staff had ensured that the relevant professionals had been involved to mitigate potential risks.

Staff maintained regular patient observations. Staff carried out searches of patients who had been out on unescorted leave. Searches were carried out to ensure that patients did not return from leave carrying items which were banned or restricted.

Restrictions that were in place were those expected for low secure wards. The service had a list of restricted items which included razors, mobile phones and shop bought medicine like paracetamol. In addition, there was a list of prohibited items which included weapons, cigarettes and tobacco products and illicit substances. The trust was in the process of reviewing its policies, including the policy in relation to restrictive practices.

The service was set on a smoke free site and patients were supported to stop smoking with the use of nicotine replacements.

Use of restrictive interventions

Staff understood the Mental Capacity Act definition of restraint and worked within it. The service used the RESPECT model of restrictive intervention. Staff told us physical restraint was only used as a last resort and only after de-escalation had been unsuccessful.

We were told by staff that there had been a period during the last 12 months where there had been a significant increase in violence on the assessment ward. Information submitted by the trust showed there were incidents in relation to physical aggression and violence towards staff where staff had sustained injury. These incidents were related to one patient who was subsequently moved to another service. However, the trust had not been required to report any RIDDOR related incidents in relation to this. RIDDOR is the reporting of injuries, incidents and dangerous occurrences regulations.

Patients that had been subject to restraint told us they understood why they had been restrained.

There have been no instances of mechanical restraint over the reporting period.

This core service had 11 incidents of restraint (on eight different service users) and 17 incidents of seclusion between 1 March 2017 and 28 February 2018. The service rarely used rapid tranquilisation. During the period from 1 March 2017 to 28 February 2018 the trust told us the service had only used rapid tranquilisation on two occasions. We checked the records in relation to these events and found observations had been carried out and records completed to reflect this. The below table focuses on the last 12 months’ worth of data: 1 March 2017 and 28 February 2018.

Ward name Seclusions Restraints Patients

restrained

Of restraints, incidents of

prone restraint

Rapid

tranquilisations

Forest Lodge 17 11 8 0 (0%) 2 (18%)

Core service

total 17 11 8 0 (0%) 2 (18%)

Information from the trust showed there had been no long-term segregation in the service between

the dates of 1 March 2017 and 28 February 2018.

Staff used the seclusion room on the assessment ward to seclude patients. We reviewed the

seclusion records for the last three occurrences of seclusion on the ward and found that records


were comprehensive and up to date. Records showed a clear reason for patients to be placed in

seclusion and gave details of what was needed to end the seclusion event.

Staff kept paper based observation records while patients were secluded and these were scanned

and uploaded when seclusion ended. Observation records we reviewed were clearly noted with

patient observations every five minutes. Staff were aware of their responsibilities in relation to

patient observations during the time they were in seclusion.

Safeguarding

A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include: physical, emotional, financial, sexual, neglect and institutional.

Each authority has its own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.

This core service made no safeguarding referrals between 1 February 2017 and 31 January 2018.

Staff working in the service were trained in safeguarding adults and children. Training compliance rates were above the trust target rate of 80%. Staff were able to give examples of potential signs of abuse and how they could report safeguarding concerns.

The service had a process in place to safely allow children to visit. Staff working on the wards were aware of this process and ensure that it was followed at all times. Prior to visiting patients staff carried out checks to ensure that the patient wasn’t prevented from seeing the young person and the young person wasn’t at risk. Visits from children were carried out in the visitor’s room and appropriate restrictions were carried out to ensure the safety of the child. This may include supervision by a staff member or other appropriate adult.

Sheffield Health and Social Care NHS Foundation Trust has submitted details of zero serious case reviews commenced or published in the last 12 months (1 March 2017 and 28 February 2018) that relate to this core service.

Staff access to essential information

The trust used an electronic patient records system. The ward manager told us that Sheffield Health and Social Care was a paperless trust and therefore all records were electronic. The system used, Insight, was a bespoke package used throughout the trust.

All permanent and bank staff could access computer records. During our inspection, we did not receive assurance that agency staff working on Forensic wards had access to the electronic system. This meant that some documents had to be printed if agency staff were required to work on the wards. However, at the factual accuracy stage, the trust stated that there were procedures in place for agency staff to access a temporary log in for the records system. Seclusion records were paper based and transferred to the electronic care record following the end of seclusion.

Medicines management

Staff kept medication records up to date and completed these correctly. Medication charts were completed electronically and this allowed for accurate stock control.

Medication charts contained information regarding patients’ prescribed medicines and known allergies. Each of the clinic rooms contained an up to date British National Formulary which ensured that staff had up to date information about medicines.

Stock medicines were kept on each of the wards. We found these were correctly stored and all medicines were within their expiration dates. The hospital pharmacy team attended the wards


regularly to ensure that stock levels were correct and none of the medicines needed to be replaced.

Staff carried out physical health monitoring in line with guidance to ensure that prescribed medicines with known side effects, like clozapine and lithium did not have a negative effect on patient’s physical health.

Track record on safety

Providers must report all serious incidents to the Strategic Information Executive System (STEIS) within two working days of an incident being identified.

Between 1 March 2017 and 28 February 2018 there were no STEIS incidents reported by this core service.

The number of serious incidents reported during this inspection was the same as what was reported at the last inspection.

Reporting incidents and learning from when things go wrong

The trust used an electronic incident reporting system. Staff who regularly worked for the trust could access the trust system and report incidents. Agency staff were unable to access this system and any incidents needed to be recorded by another staff member.

Post incident reviews and debriefs took place for staff and patients. Managers discussed incidents during team meetings, clinical supervisions, and individual one to ones. Staff also took part in weekly meetings which allowed them to reflect on the events of the week.

Staff were aware of their responsibilities under the duty of candour. The trust provided us with information relating to audits. Internal auditors, 360 Assurance, had carried out a recent audit and the trust had been rated as giving ‘significant assurance’ that reportable events would be reported.

Staff working in the service had received training in the Duty of Candour. Training included the statutory duty and individual responsibilities in relation to the Duty of Candour.

If there were lessons learned following an incident, staff were given information via several methods. This included, meetings, clinical supervisions and appraisals.

The Chief Coroner’s Office publishes the local coroners Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.

In the last two years, there have been zero ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.


Is the service effective?

Assessment of needs and planning of care

Admissions to the service were planned. Prior to admission an access assessment was carried out by a consultant psychiatrist and discussed with commissioners. Once a patient was admitted to the ward, nursing staff carried out a comprehensive assessment. The admission assessment covered a variety of things including, physical description, Mental Health Act status, mental and physical health history and current medication. Physical health examinations were carried out on all patients admitted to the service.

We looked at the care records for eight patients who used the service and found that of these six contained a completed care plan and four had been regularly reviewed. Two of the patient records we looked at did not contain a completed care plan. Care plans we reviewed were holistic, personalised and recovery oriented. Care plans outlined the support patients required to meet their mental and physical health needs and included needs identified during the initial assessment. Risk factors were identified in care plans and actions included to mitigate risks.

Best practice in treatment and care

There were a range of suitable care and treatment interventions for patients. This included psychological therapies, medication and education. Education formed a large part of the activity timetable which meant that patients who did not wish to pursue educational routes were restricted in their options.

Patients had access to physical healthcare when needed. Staff arranged for patients to see their own preferred specialists or ensured that they were registered with a local service. This included dentists, podiatrists and opticians. Patients with existing physical health problems were referred to local services where they were able to see a suitable specialist. Where this was not possible arrangements were made for them to be seen by the appropriate specialist at the hospital.

Staff used ratings scales to measure severity and outcomes. We saw the service used the health of the nation outcome scale and malnutrition universal screening tool.

The core service was pursuing a plan to allow patients independent access to the internet. Staff had been working with patients and formulating appropriate risk management strategies to enable this.

The provider told us this core service participated in the following clinical audits as part of their clinical audit programme in the 12 months leading up to the submission of the provider information return.

Audit name Audit scope Core service Audit type Date

completed

Key actions following the

audit

Collaboration

with Primary

Care Clinicians

Service users

on CPA

Provider

wide Clinical on-going

Changes made following

previous audit round:

provide guidance to staff

on annual reviews of care.

Changes to care plan form.

Creation of a 'clinical

review for GP' IT system

solution.

Record keeping

audit 2016/2017 Trust wide

Provider


From data collected so far:

Further clarity provided to

staff on use of

abbreviations - to be

incorporated into the

relevant policy.

Audit of risk Trust wide Provider Clinical audit March 2017 Local action plans to


assessments

2016/2017

wide address identified issues.

Audit tool to be revised to

give clearer results.

Re-audit to be undertaken

in 2017/18.

Audit of risk

assessments

2017/2018

Trust wide Provider

wide Clinical audit ongoing Await findings

Audits of care

plans Trust wide

Provider

wide Clinical audit

January

2018

Agreed need for frequent

small-scale audits.

Findings being shared with

teams.

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG43

Transition from

children’s to

adults’ services

for young

people using

health or social

care services

Trust wide Provider

wide Clinical audit June 2017

Findings fed into

Commissioning for Quality

and Innovation and other

related joint work with child

and adolescent mental

health services to improve

transitions

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG13

Workplace

health:

management

practices

Trust wide Provider

wide Clinical audit

September

2017

Review practices against

guidance as necessary in

future

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG58

Coexisting

severe mental

illness and

substance

misuse:

community

health and

social care

services

Trust wide Provider

wide Clinical audit

December

2017

Action plan under

development

Staff we spoke with told us they participated in local audits, including infection control audits, clinic room checks and health and safety audits. Concerns were highlighted and an action plan was drawn up which staff were required to complete. We saw evidence of actions being carried out following audits.


Skilled staff to deliver care

The service had access to a range of specialists required to meet the needs of patients. The multi-disciplinary team consisted of doctors, nurses, health care support workers, psychologists and occupational therapist.

Staff working on the ward were required to complete the trust induction process. This included bank staff.

We asked the trust for information in relation to the completion of staff appraisals.

The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal rates for non-medical staff within this core service was 100%.

The rate of appraisal compliance for non-medical staff reported during this inspection was the same as what was reported at the last inspection.

The table below shows the number of non-medical staff who received an appraisal in the last 12 months:

Ward name

Total number of

permanent non-medical

staff requiring an

appraisal

Total number of

permanent non-

medical staff who

have had an appraisal

% appraisals

Forest Lodge 55 55 100%

Core service total 55 55 100%

Trust wide 1495 1440 96%

The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal rates for medical staff within this core service was 100%.

The rate of appraisal compliance for non-medical staff reported during this inspection was the same as what was reported at the last inspection. The table below shows the number of permanent medical staff who have received an appraisal in the last 12 months:

Ward name

Total number of

permanent medical staff

requiring an appraisal

Total number of

permanent medical

staff who have had

an appraisal

%

appraisals



Trust wide 57 56 98%

The trust’s target for clinical supervision is 66%.

Between 1 March 2017 and 28 February 2018, the rate across all teams in this core service was 44%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was lower than the 60% reported at the last inspection.


Ward name Clinical supervision

sessions required

Clinical

supervision

sessions delivered

Clinical

supervision rate

(%)



Trust Total 3420 2183 64%

Staff had regular supervisions, both individually and as a group. However, this included management supervisions. Figures submitted by the trust showed that the number of clinical supervisions carried out was 44%, which was below the trust target of 66%. Supervisions and appraisals were recorded and contained details of discussions and the staff members performance.

Information provided by the trust showed that clinical supervision for medical staff was 300%. This meant that medical staff had three times the number of clinical supervisions required by the trust.

Multi-disciplinary and interagency team work

The multi-disciplinary team worked closely to provide the best outcome for the patient. Weekly multi-disciplinary team meetings were held which all staff were required to attend. There were hand overs at the start of each shift and these were used to pass on important information regarding patient.

Staff communicated with care co-ordinators regarding patients and their progress. Care co-ordinators and social workers were invited to attend meetings regarding patients care and treatment.

Adherence to the Mental Health Act and the Mental Health Act Code of

Practice

As of 28 February 2018, 88% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years.

The training compliance reported during this inspection was lower than the 94% reported at the last inspection.

The majority of staff we spoke with told us they had received training in the Mental Health Act and the code of practice, although one staff member told us they didn’t recall having the training.

Staff had a good working knowledge of the Act and the associated code of practice. Staff told us they were able to access help and support via the trust Mental Health Act office but were also aware that information was available via the trust intranet.

Staff told us patients had access to Independent Mental Health Advocates and they visited the service regularly. Patients we spoke with confirmed they knew about the availability of advocates and some told us they used an advocate.

Staff explained patient rights under the Mental Health Act. Patient’s rights were explained to them when they were admitted to the ward and regularly after that. One staff member told us patients had their rights explained after there were changes in their care and treatment or if their legal status changed. Another staff member told us patients had their rights explained to them every three months.

Section 17 leave forms were completed correctly and were up to date. Section 17 forms show the amount of time patients are able to spend outside the hospital and if there are any conditions to


this leave. For example, if they required a member of staff to escort them and if their leave was within the hospital grounds or if they could leave the site.

During our inspection we looked at the medication charts for all patients in the service. We found all charts had a valid T2 or T3 form in place. A T2 form is used when a patient has the capacity to make decisions about their treatment and they have given their consent for treatment. A T3 is used if the patient either does not consent to treatment, or does not have the capacity to make decisions about their treatment. In these cases, a request for a second opinion approved doctor must be submitted via the CQC to review the treatment plan and discuss it with the patient.

The trust completed weekly audits to ensure that patients had their rights explained to them. However, there were no other audits being carried out in relation to the Mental Health Act or Mental Health Act documentation.

Meetings were held prior to discharge to arrange care and support. When patients could be discharged multi-disciplinary team, meetings were held to discuss the section 117 aftercare needs of the patient. Section 117 aftercare is support that is available to patients who have previously been detained under certain sections of the Mental Health Act.

Good practice in applying the Mental Capacity Act

As of 28 February 2018, 97% of the workforce in this core service had received training in the

Mental Capacity Act Level 1 and 89% of the workforce had Mental Capacity Act Level 2. The trust

stated that this training is mandatory for all core services for inpatient and all community staff and

renewed every three years.

The training compliance reported during this inspection was higher than the 27% (Mental capacity act level 1) and 47% (Mental capacity act level 2) reported at the last inspection.

All the staff we spoke with demonstrated a good working knowledge of the Mental Capacity Act and were able to name the statutory principles.

The trust had a policy which related to the Mental Capacity Act and included information on the deprivation of liberty safeguards. Staff were able to access the policy and information regarding the Mental Capacity Act via the trust intranet.

Care records we looked at showed evidence of capacity assessments being completed and consent being sought for treatment. Where patients lacked capacity, we saw evidence of decisions being made in patients’ best interests.

All the patients who receive care and treatment in secure forensic mental health wards are detained under the Mental Health Act. Therefore, there were no deprivation of liberty safeguards applications made within the last 12 months for this core service.


Is the service caring?

Kindness, privacy, dignity, respect, compassion and support

Staff treated patients with kindness, dignity and respect. We observed staff interacting with patients and saw that staff treated patients respectfully at all times.

Patients we spoke with told us that staff were helpful and treated them well. However, patients told us that agency staff did not help them and they felt the ward was ran better when the permanent staff were working.

Staff were seen speaking with patients, talking to them about their plans for the day and what they had done the previous day.

Care plans showed evidence that staff had spoken to patients about their care and had helped them to understand their treatment.

Patients told us they felt able to raise concerns with staff and that these would be taken seriously.

The 2017 Patient-Led Assessments of The Care Environment (PLACE) score for privacy, dignity and wellbeing at this core service location scored higher than similar organisations.

Site name Core service(s) provided Privacy, dignity

and wellbeing

Forest Lodge Forensic secure 100%

Trust overall 97%

England average (mental health

and learning disabilities) 91%

Involvement in care

Involvement of patients

New patients were given information about the service before they arrived. Patients were provided with a welcome book which gave them information about the service. This included a list of restricted items, meal times, visiting times, information on how to make a complaint and expectations regarding behaviour on the ward and toward others.

Care plans and risk assessments showed limited evidence of patient involvement. Although patients attended meetings to discuss care, care plans did not always reflect this. We looked at the care records of eight patients and found four showed no evidence of patient involvement. The other four care plans we looked at showed evidence that patients had discussed their care with staff and care plans had been agreed. The manager and deputy manager both told us the service was to start collaborative care planning the week following our inspection.

Wards had regular community meetings which patients could use to discuss concerns, share their views and feedback on issues which mattered to them. We saw evidence in the form of ‘you said, we did’ boards, that the trust had listened to, and acted upon comments from patients.

The service had booklets available for patients. These included, ‘Who will be involved in my care’, ‘Clinical psychology’ and ‘occupational therapy’. The booklets gave patients information regarding the work of clinical psychologists and occupational therapists as well as telling them about the role of other members of the multi-disciplinary team. However, patients we spoke with did not recall receiving any of these booklets and there was no record of patients receiving these.

Involvement of families and carers

Patients could make a choice about the involvement of family in their care. Patients we spoke with told us that their relatives were made welcome in the service. Care records showed that staff had recorded the views of patients, families and carers as appropriate.


Is the service responsive?

Access and discharge


Bed management

The trust provided information regarding average bed occupancies for two wards in this core service between 1 March 2017 and 28 February 2018.

The table below shows the average range in bed occupancy for the ward across a 12-month period:

Ward name Average bed occupancy range (1 March 2017 and 28

February 2018) (current inspection)

Forest Lodge Assessment 73.6%-109.1%

Forest Lodge Rehab 87.7%-100.3%

The trust provided information for average length of stay for the period 1 March 2017 and 28 February 2018.

We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the period that was covered.

Ward name Average length of stay range (1 March 2017 and 28


Forest Lodge Assessment 93-1582

Forest Lodge Rehab 499-1038

This core service reported one out of area placement between 1 March 2017 and 28 February 2018.

As of 28 February 2018, this core service had no ongoing out of area placements.

This core service reported zero readmissions within 28 days between 1 March 2017 and 28 February 2018.

Discharge and transfers of care

Between 1 March 2017 and 28 February 2018, there were 15 discharges within this core service. This amounts to 2% of the total discharges from the trust overall (804).

There were no delayed discharges between 1 March 2017 and 28 February 2018.

Referral to assessment and treatment times was not provided for this service.

Prior to admission, the consultant carried out an assessment. There were clear treatment pathways in place and staff were aware of these and how they helped to support patients if their mental health deteriorated.

Although the wards had different purposes, discharge was possible from any of these. When staff felt patients were ready for discharge they were usually transferred to the rehabilitation ward, however, this was not always the case and staying on the assessment ward did not prevent discharge.

Some of the patients in the service were not able to be given leave or discharged from hospital without appropriate authority from the Ministry of Justice. Where this was the case, we found proper authority had been sought prior to discharge.

Facilities that promote comfort, dignity and privacy

All patients had their own bedrooms; however, only one room across the two wards had en-suite facilities. Patients were able to personalise their bedrooms and could take personal belongings in to the hospital, as long as there was nothing on the prohibited items list. Patients were able to lock personal items in their bedrooms and were also provided with a locker.


Patient bedrooms had viewing windows fitted into the doors. Viewing windows had integrated blinds with could be opened and closed as needed. Patients were able to open and close blinds from inside their rooms. Staff used a key if they needed to see inside. This meant they met national standards for secure services.

Staff on the assessment ward told us they did not carry out a traditional medicine round. Patients were given the choice of where they wanted to have their medication. Some patients preferred to have their medication in their room, some in the clinic room and others were happy to have their medicine in the communal area of the ward. Although this meant some patients’ privacy could not be guaranteed, they were able to ensure patients were comfortable about taking the required medication.

Patients had access to space and facilities. Patients on both wards had access to secure garden space, pool table and computers. However, the patients on the rehabilitation ward did not have access to exercise equipment due to the ongoing works.

Access to the gardens on the assessment ward was via a locked door. Patients were only able to access the garden with staff authority and a member of staff was required to be in the garden with them. If more than one person wanted to access the garden another staff member of staff was also required. Patients on the rehabilitation ward were given unrestricted access to outdoor space.

Patients on both wards were able to access hot food and drinks, although patients were not able to prepare their own hot drinks due to the size of the kitchen on each ward.

The 2017 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at the location scored lower than similar trusts.

Site name Core service(s) provided Ward food

Forest Lodge Forensic Inpatient 87.4%

Trust overall 96%

England average (mental health and learning disabilities) 92%

Patients’ engagement with the wider community

Staff ensured that patients had access to education opportunities. The service offered patients access to their recovery college which provided them with the ability to gain qualifications, learn about their illness and learn about other things they were interested in. The prospectus included things like music appreciation, GCSE English and maths and substance misuse and mental health. Courses were running at Forest Lodge which meant all patients could take advantage of them.

Staff supported patients to maintain relationships with family and friends. Patients were able to see family and friends in the visiting room at the service. All visits were by previous arrangement and if patients did not have the ability to leave the hospital visits were carried out in the visitor’s room.

Staff ensured that patients had appropriate spiritual support. The service did not have a dedicated multi-faith room however, the visitors room could be used if it was available. Patients were also able to access spiritual support through the trust’s chaplaincy service.

Meeting the needs of all people who use the service

Patients were able to access sports, leisure and education based activities, however, the majority of these were part of the service recovery college. Weekend activities were limited on both wards.

Appropriate adjustments were not always made when required. The trust had a library of information which had been translated into multiple languages. At the time of our inspection we found that patients who did not have English as a first language had not been provided with information in another language. Although interpreters had been arranged, patients did not always


have important documents translated. For example, we found that the patient had their rights explained to them by a member of staff using their first language however, this was not recorded on their care plan and the document they had been asked to sign was in English. In addition, we found that the patient did not have a communication care plan in place and did not have a copy of their care plan.

Although the wards and visitors room were on the ground floor, the service was not accessible to disabled visitors. There was no ramp at the service entrance and doors had not been widened to allow for wheelchair access.

The ward manager told us the service was unable to take patients who had mobility concerns. Although bathrooms had recently been refitted and contained grab rails to assist patients, none of the bedrooms were suitable for patients in wheelchairs. Any patients that had mobility needs and required low secure services had to be placed in services out of the area.

Equality and diversity was promoted on the ward. There was a zero-tolerance attitude to abuse in the form or discrimination. Some staff told us they had been subject to racist abuse by a patient. Staff told us that although they ignored this behaviour, the ward manager ensured that incidents were reported and the patient was told the behaviour was unacceptable. This ensured that both patients and staff were aware of the trust policy in relation to discrimination and abuse. Patients we spoke with told us that they had not experienced any discrimination while on the ward.

Listening to and learning from concerns and complaints

Patients we spoke with told us they knew how to make a complaint. We were told by patients that

they would speak to staff or make a complaint with the help of advocates.

We asked the provider for information on complaints and compliments the core service received.

This core service received two complaints between 1 March 2017 and 28 February 2018.

Ward

name

Total

Complaint

s

Fully

upheld

Partially

upheld

Not

upheld

Referred to

Ombudsman

Upheld by

Ombudsman

Assessm

ent ward 2 0 0 2 0 0

This core service received zero compliments during the last 12 months from 1 March 2017 and 28

February 2018.


Is the service well led?

Leadership

Leaders had the skills, experience and knowledge to carry out their roles. The trust recruitment process was comprehensive and job adverts contained all essential information.

Senior managers were aware of incidents and concerns related to the services they managed and ensured that they were kept informed of investigations that were being carried out.

Vision and strategy

Staff were aware of the trust’s vision and all were able to tell us some of the trust’s values. Trust values were part of the appraisal process and staff were measured on their day to day performance in relation to these.

Local managers felt supported by senior managers. Senior managers did not visit the service often; however, the service director spent a lot of time there helping with the service recovery college.

Culture

The majority of staff told us they felt supported in their roles. Most of the staff we spoke with told us they were happy and enjoyed their work. However, we were also told that staff had experienced incidents of violence and had been subject to several episodes of verbal abuse. Staff told us they felt things had improved recently and particularly since a new deputy ward manager had been appointed.

Staff told us about incidents that had occurred on the ward and the support they had received from managers, both within the service and also from more senior management.

Staff felt able to raise concerns without fear of retribution. Staff were aware of the trust whistleblowing policy and knew about the trust freedom to speak up guardian. Staff told us The freedom to speak up guardian had visited the service the week before our inspection and staff told us they had used that visit to raise concerns about the service. These were to be investigated.

Poor performance was addressed using trust policies and procedures. The ward manager told us staff performance was reviewed during supervision and appraisals. If there were concerns regarding staff performance these were usually addressed as part of the supervision and appraisal process, dependent on what the concern was.

We asked the provider for details of any incidents which had resulted in staff being investigated. During the reporting period, there was one case where staff were moved to a different ward while under investigation.

Caveat: Investigations into suspensions may be ongoing, or staff may be suspended, these should be noted.

Ward name Suspended Under

supervision

Ward move Total

Forest Lodge 1 0 0 1

Core service total 1 0 0 1

Staff achievements were recognised through a trust award scheme.


Governance

Mandatory training levels were high with all but one above the trust target level. Staff had regular supervisions however they did not receive the required number of clinical supervisions necessary for their roles.

There were usually enough staff to meet the needs of the patients and the acuity of the ward environment however, the staffing tool used was for acute wards and was not always appropriate for low secure wards.

The service was clean and tidy and there were systems and procedures in place to ensure staff completed tasks relating to this. A team of housekeepers were employed and were responsible for ensuring cleanliness. Ward restrictions were appropriate to the security of the service. Additional restrictions were in place for some patients following the completion of risk assessments.

Renovation work had been completed on all bathrooms in the service to ensure these were now ligature free. Doors within the service were in the process of being replace with anti-barricade doors. All bedroom doors had viewing panels to promote patient privacy.

Senior managers were aware of issues within the core service through a variety of meetings. There were regular meetings in place for patients, core service staff and managers. Minutes of these meetings were taken and made available to appropriate audiences.

The service had introduced a recovery college for patients where they could access education opportunities. This included participation in sports, learning about their illnesses or working towards a recognised qualification. However, patients who did not wish to enrol were provided with only limited activities.

The trust had reviewed a number of policies prior to our inspection. However, although these had been ratified, the majority of staff on the wards were not aware of the new policies and there was no implementation plan in place for the service.

The trust provided evidence of changes which had been implemented following incidents. Staff we spoke with told us they were informed of lessons learned and investigation outcomes.

Staff took part in clinical audits which were conducted at a local level. These included Mental Health Act, clinic room and fridge temperatures, mattress and pillow audits and infection control audits. Audits were carried out to ensure the quality and continued improvement of the service.


Managers were able to add items to the trust risk register. The ward manager knew how to escalate concerns and was aware of the trust governance structure.

Regular checks were carried out to ensure the building was safe. Environmental risk assessments were regularly carried out and used to identify potential risks to staff and patients. Areas of concern and potential risk were identified and steps were taken to minimise risks. We looked at the risk register for the core service and found there was one entry which was assessed as high and regarded the environment of the core service. This risk was the seclusion room which had been identified as unsuitable.

Information management

The trust used systems to collect data from wards and used it to assist managers with the reviewing of key performance indicators.

Permanent and bank staff could access the records they needed with the use of computer systems. The trust used a bespoke computer package which included care records, policies and guidance. If agency staff were required to work on the ward, information would need to be printed as they did not have access to computerised records.

Engagement


The trust has an intranet system which provided staff with information and news from around the trust as well as having up to date information on trust policies and procedures. There was also a website which allowed public access to information, including trust policies, contact information, trust directors and wards.

Patients and their families were asked for their feedback on the service via questionnaires. There was also a comments box in one of the communal areas between the wards. The service had a ‘you said, we did’ board in the service to ensure patients and their families were aware of changes that were carried out.


NHS Trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.

There were no accreditations for this core service.


Long stay/rehabilitation mental health wards for working age adults



female, mixed)

Forest Close Forest Close,

Bungalow 1a 14 Male


Bungalow 1 8 Female


Bungalow 2 8 Female

Forest Close is an in-patient rehabilitation service provided by Sheffield Health and Social Care

NHS Foundation Trust. The service is based in Middlewood, North-West Sheffield. It is composed

of three wards and an additional unit called the learning and recreation hub, which is a therapy

and activity centre. (At our previous inspection in 2016, this unit was called bungalow three).

Forest Close provides long-term and rehabilitation care for people with severe and enduring

mental health needs who require support to reach their optimum level of recovery. The service

accepts all adults aged 18 years and over, irrespective of gender, ethnicity, sexuality, culture or

physical abilities. There was no upper age limit for the service.




We checked all three ward environments and the learning and recreational hub, as well as the

documentation relating to the environments to consider if they were safe and clean.


All three wards and the learning and recreational hub settings were safe. Staff completed annual

environmental risk assessments for each ward and the learning and recreational hub. Staff

monitored all ward areas via a secure entry system and checked identification before allowing

people onto the ward. All areas displayed a notice informing everyone about items that should not

be brought on the wards for safety reasons such as weapons and cigarette lighters.

All visitors signed a visitor’s book to comply with security and fire procedures. All staff received

mandatory fire training every two years and the service training compliance was higher than the

trust target. All areas had the fire equipment they needed. Staff checked fire equipment regularly

and completed patients’ personal evacuation plans. Staff knew about the fire safety procedures for

their areas and carried out fire drills to test out their procedures in the event of fire.

All staff carried personal alarms that they checked regularly to make sure they worked. During the

inspection, staff issued inspectors with personal alarms and explained how to use them in an

emergency. The alarm system across all three wards was integrated that meant staff from other

wards were alerted when an alarm sounded. At the learning and recreational hub the alarms were

not integrated into the ward system. This was an area for improvement identified at our previous

inspection in 2016. We told the trust it must mitigate the risk of harm to staff and patients using this

area. At this inspection, we found that staff had taken other action in response to our concerns.

Staff carried out individual patient risk assessments and always accompanied patients in this area.

The absence of an integrated alarm system was included on the service risk register and

refurbishment plans included work to integrate the system. However, managers could not provide

a confirmation date for completion of the work.

Over the 12month period from 1 March 2017 to 28 February 2018 there were zero mixed sex accommodation breaches within this core service.

All three wards provided single sex accommodation, which meant all wards complied with

Department of Health guidance on eliminating mixed sex accommodation.

Information provided in the pre-inspection information confirmed that there were ligature risks in four areas within this core service. The trust had undertaken recent (from 28 April 2017 onwards) ligature risk assessments at four locations.

None of the four locations presented a high level of ligature risk and all locations presented some risk due to the acuity of service users and the remaining anchor points (Door handles, door corners, grab rails/mobility aids).

The trust had taken the following actions in order to mitigate ligature risks: risk management of service users includes risk assessment, observation levels and the removal of items that may be used. In addition, the learning and recreation hub is a fully supervised area.

During the inspection visit, we confirmed that each area had an up to date environmental ligature risk assessment that managers reviewed and updated when things changed. We observed ligature anchor points that were all included on the risk assessments. These are places where people intent on self-harm might tie something to strangle themselves. Staff managed blind spots


by carrying out individual patient risk assessments and observations. One ward had plans to fit a convex mirror to improve observation in one area.

Staff had measures in place to maintain patients’ safety on the wards. All three wards had a nurse call system available in every room for patients to use if they needed help. When patients used the learning and recreation hub, staff who carried alarms were always present with them.


At our previous inspection in 2016, we raised concerns about the cleanliness of bungalow three

(now called the learning and recreation hub) and incomplete cleaning records. We told the trust

that it must ensure that all areas used for patient care are clean. At this inspection in 2018, we

found that all three wards and the learning and recreation hub had reliable systems and processes

to keep the wards clean and people safe. Staff were clear about their responsibilities, they kept up

to date cleaning records and all areas were clean. The wards were well maintained and provided

comfortable furnishings. All patients and carers we spoke with told us that wards were always

clean and comfortable.

At our previous inspection in 2016, we raised concerns about how staff ensured that food was

stored safely. We told the trust that it should ensure that staff take action when the temperature in

fridges used to store food exceeds five degrees. At this inspection in 2018, we found that the

service had made improvements. Staff checked fridge temperatures daily and recorded their

actions where fridge temperatures were not in the correct range.

All staff completed mandatory health and safety training and the service training compliance was

higher than the trust target. The site services officer raised maintenance requests for repairs and

improvements. At the time of our inspection, we saw housekeeping staff present on the wards and

trust maintenance staff working across the site. However, during the inspection we saw that not all

staff wore footwear that provided adequate protection and did not adhere to the trust dress code

policy.

All staff completed mandatory hand hygiene training and the service training compliance was

higher than the trust target. The service completed infection control audits and took part in

infection control roadshows provided by the trust. All areas had hand sanitisers available for staff

to use in addition to handwashing facilities. However, not all staff adhered to the trust dress code

and infection control principles. We observed staff across all three wards that had not tied up their

long hair or wore excessive jewellery and unsuitable footwear.

Patient led assessments of the care environment are carried out by local people who visit services

and assess the care environment. For the most recent Patient-led assessments of the care

environment (PLACE) assessment 2017 the location had a higher score than the similar trusts for

three of the four aspects overall and was not rated for the dementia friendly criteria.


provided


appearance

and

maintenance

Dementia

friendly

Disability

Forest Close

MH - Long

stay/rehabilitation

mental health wards

for working age adults

99.7% 99.8% - 92.7%



provided


appearance

and

maintenance

Dementia

friendly

Disability

Trust overall 99.0% 96.4% 91.1% 91.8%

England average (Mental health

and learning disabilities) 98.0% 95.2% 84.8% 86.3%

Seclusion room

The wards did not have any seclusion facilities and did not seclude patients.


All three wards had clinic rooms where staff stored medication, equipment, and medical supplies.

The rooms were too small for an examination couch, which meant staff carried out physical

examinations with patients in their bedrooms. All clinic rooms were fully equipped with accessible

resuscitation equipment and emergency medicines that staff checked weekly. Staff maintained

equipment and kept it clean so that it was safe to use. However, staff did not have robust

procedures for date checking stock medical items. We found out of date items including dressings,

alcohol wipes, and urinalysis sticks in two ward clinic rooms.

Safe staffing

Nursing staff

There was enough adequately trained and skilled staff on duty across all three wards. The clinical

nurse manager and ward managers planned and reviewed staffing levels and skill mix daily.

The minimum establishment levels were set for each ward. Qualified nurses and support staff

worked across three shifts and managers usually worked between Monday and Friday during the

day and complimented the staffing establishment. The shift system across all three wards was

07.00 until 15.00, 13.30 until 21.30 and 21.18 until 07.10. Some staff worked a 'cross over' shift

that meant they worked flexibly over the two day shifts. The non-medical prescriber and senior

nurse practitioner also provided support to all three wards.

The service had agreed staffing levels. Ward one A had the largest staffing establishment for 14

patients with five staff each shift during the day with two qualified nurses, and three staff at night

with one qualified nurse. On wards one and two, staffing was three staff per shift during the day

and two at night with one qualified nurse on every shift. The manager told us that they could adjust

staffing levels easily and used additional staff from the trust bank or agency if needed.

At our previous inspection in 2016, we raised concerns about low staffing because staff reported

incidents of low staffing and sometimes one nurse covered more than one ward. We told the trust

that it must ensure that there is always at least one qualified nurse for each bungalow. At this

inspection in 2018, we checked the most recent staffing rotas and incidents related to low staffing

and found the trust had made improvements. The use of bank or agency staff was low and the

service had no vacancies for qualified nurses or support staff. This was because managers had

recently recruited to vacant posts. The managers knew about staff who would be leaving such as

retirement and had succession plans in place. This meant that managers could recruit staff in a

timely way and minimise any gaps in staffing. Staff and patients told us that there was usually

enough staff on duty and we saw that staff had enough time to spend with patients.


The wards provided adequate and accessible medical cover that included dedicated consultant

psychiatrists, specialist and trainee doctors. All three wards had access to a doctor’s rota that was

updated by the trust. This meant staff knew which doctors to contact. In addition, the service had

two nurses who had completed additional training to become non-medical prescribers and a GP

visited all three wards weekly. Staff used the trust on call system for medical advice out of hours if

needed.

The trust provided details of staffing in the table below.

Definition






7.6 N/A


6% 13%


Total vacancies overall (excluding seconded staff) At 31March 2018 -9 N/A

Total vacancies overall (%) At 31March 2018 -10% NA



6% 5%


6% 5%




Number of vacancies, qualified nurses (WTE*) At 31 March 2018 -5 N/A

Number of vacancies nursing assistants (WTE*) At 31 March 2018 -6 N/A

Qualified nurse vacancy rate At 31 March 2018 -17% N/A

Nursing assistant vacancy rate At 31 March 2018 -15% N/A

Bank and agency Use



February 2018 162 (3%) N/A


(Qualified Nurses)

1 March 2017 and 28

February 2018 9 (>1%) N/A



1 March 2017 and 28




1 March 2017 and 28

February 2018

722 (10%)

N/A



1 March 2017 and 28

February 2018 9 (>1%) N/A




1 March 2017 and 28



This core service reported an overall vacancy rate of -10%for registered nurses at 31 March 2018.

This core service reported an overall vacancy rate of -17% for qualified nurses (negative numbers indicate an over establishment). This core service reported an overall vacancy rate of -15% for registered nursing assistants.


Ward/Tea

m

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Forest

Close

Ward 1A

1 11 9% 2 16 13% 3 27 11%

Forest

Close

Central

-1 4 -25% 0 3 0% 1 30 3%

Forest

Close

Ward 1

-4 7 -57% 0 10 0% -4 17 -24%

Forest

Close

Ward 2

-1 7 -14% -8 10 -80% -9 17 -53%

Core

service

total

-5 29 -17% -6 39 -15% -9 91 -10%

Trust total 32 433 7% 15 353 4% 68 1339 5%



In the same period, agency staff covered less than 1% of shifts for qualified nurses. Two percent of shifts were unable to be filled by either bank or agency staff.

Forest Close Central is an administration area and no patient care is provided in this area.

Ward/Team Available shifts Shifts filled by bank staff Shifts filled by

agency staff


or agency staff

Forest Close,

Bungalow 1

1450 34 (2%) 0 (0%) 57 (4%)

Forest Close,

Bungalow 1a

1972 64 (3%) 2 (>1%) 16 (1%)

Forest Close,

Bungalow 2

1347 64 (5%) 7 (1%) 4 (>1%)

Core service

total

4769 162 (3%) 9 (>1%) 77 (2%)

Trust Total 32,394

4977

(15%)

7252

(22%)

900

(3%)




In the same time period, agency staff covered less than 1% of shifts. One percent of shifts were unable to be filled by either bank or agency staff.


agency staff

Shifts NOT filled by bank or

agency staff

Forest Close,

Bungalow 1

2084 190 (9%) 6 (>1%) 10 (>1%)

Forest Close,

Bungalow 1a

2816 266 (9%) 3 (>1%) 39 (1%)

Forest Close,

Bungalow 2

2108 266 (13%) 0 (0%) 8 (>1%)

Core service

total

7008

722 (10%)

9 (>1%) 57 (1%)

Trust Total

59,514 21,770

(37%)

5623

(9%)

1760

(3%)


This core service had 7.6 staff leavers between 1 March 2017 and 28 February 2018.



Forest Close Bungalow 1 21.4 5.8 10%

Forest Close Bungalow 1A 26.03 1.8 7%

Forest Close Central 28.24 0 0%

Forest Close Bungalow 2 20.9 0 0%


Trust Total 1351.6 129.6 8%

The sickness rate for this core service was 6% between 1 February 2017 and 31 January 2018. This was similar to the sickness rate of 7% reported at the last inspection in 31 July 2016.


(at latest month)



Forest Close Bungalow 2 8% 8%

Forest Close Central 2% 6%

Forest Close Bungalow 1 7% 5%

Forest Close Bungalow 1A 10% 5%


Trust Total 8% 7%


The below table covers staff fill rates for registered nurses and care staff during November 2017, January 2018 and February 2018 (December 2017 information is missing).

In February 2018, Forest Close – W1a had fill rates of below 90% for care staff during day shifts. In February 2018, Forest Close – W2 had fill rates over 125% for care staff during night shifts. Key:

> 125% < 90%

Day Night Day Night Day Night

Nurses

(%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff (%)

Nurses (%)

Care staff

November 2017 January 2018 February 2018

Forest Close – Bungalow 1

121.9 107.8 93.3 97.1 114.4 103.9 100.3 116.1 118.6 96.1 100 92.9

Forest Close – Bungalow 2

108.9 104.2 100.9 101.5 124.5 94.2 103.4 122.3 109.4 111.7 103.6 136.0

Forest Close – Bungalow 1a

109 92.3 100 100 104.4 94 100 104.1 108.2 84.3 100 102

Medical staff

Between 1 February 2017 and 31 January 2018, no shifts were filled by bank staff to cover

sickness, absence or vacancy for medical locum shifts.

Mandatory training

The trust had mandatory training requirements for all staff to complete. Mandatory training was

made up of a mixture of on-line and face-to-face training. At our previous inspection in 2016, we

raised concerns about low compliance with mandatory training across the service. This was

because we were not assured that staff were competent and had the skills they needed to perform

their roles. We told the trust that it must improve mandatory training compliance. At this inspection

in 2018, we found that the service had improved their mandatory training compliance to reach 75%

and above for all 22 mandatory training courses. Twenty-one of the courses exceeded the trust

target of 80%. The lowest compliance was 75% for dementia awareness. Five courses had 100%

compliance, including risk assessment and respect training. The service had identified a

mandatory training champion who ensured that all staff kept up to date. Managers had oversight of

compliance via a trust electronic dashboard and regularly monitored mandatory training

compliance. Staff told us how they kept their training up to date and about the difficulties they

experienced accessing the on line e-learning system at times.

The trust reported the compliance for mandatory and statutory training courses at 28 February

2018 was 96%. Of the training courses listed one failed to achieve the trust target.

Key:





Trust target % Trust wide mandatory/ statutory training total %





Falls) 100%

80% 97%



















Dignity standards) 75%

80% 85%

Core Service Total % 96% 88%


During the inspection, we reviewed care records for 12 patients from across the service.


Staff assessed, managed, and monitored patients to keep people safe. Staff completed the trust

electronic risk assessment tool called the detailed risk assessment management tool. This tool

has been adapted from the Distress and Risk Assessment Method, a nationally recognised risk

assessment tool to meet the needs of the service. Risk was reviewed in line with the trust policy.

This included at initial assessment, on admission, at regular multidisciplinary reviews or sooner if

needed.


All 12 records demonstrated that staff completed timely and comprehensive risk assessments and

management plans that they reviewed regularly. We observed multidisciplinary meetings and staff

handovers that included discussion about patient risks and management plans.

Staff observed all patients according to their individual observation levels that meant that staff

checked on patients’ safety at regular times during the day and night. Staff followed the trust

observation policy and could increase the frequency of observations quickly if risks changed. All


seven patients we spoke with told us they felt safe on the ward and carers felt confident that staff

kept their relatives safe.

Staff did apply some blanket restrictions. These are restrictions on patients that staff had not

individually risk assessed and applied to all patients on all three wards. At our previous inspection

in 2016 and at a previous Mental Health Act Reviewer visit in 2017 we commented about blanket

restrictions. We told the trust that it must review blanket restrictions to ensure that care is

personalised for each patient. At this inspection in 2018, we found that each ward held a file with

information about the blanket restrictions. These restrictions were appropriate for the service and

approved on the trust wide blanket restriction register in March 2018. Restrictions included;

takeaway foods, smoke free environments, e-cigarettes and locked doors. Visiting times were

flexible and could take place between 10am and 8pm. Meal times were protected, therefore, visits

were not encouraged between 12pm and 1.30pm and 5pm and 6.30pm.

The service informed patients and their relatives about the blanket restrictions before and on

admission to the ward. Staff discussed and recorded the impact of the blanket restrictions with

each patient and included management plans in their care plans and risk assessments. Staff also

continued to discuss the impact of blanket restrictions at patient community meetings. For

example, staff encouraged patients to eat healthy meals and asked patients to get one takeaway

meal per week. We saw evidence of how staff reduced restrictive practice in response to patients’

feedback about conducting leave risk assessments. Staff asked that patients should be out of bed

one hour before they went on leave so that they could complete a risk assessment. This had

changed from two hours in response to patient’s feedback.

The doors to all three wards were secure and needed a key code for entry and exit. All three

wards displayed a notice about the locked doors and informed patients how they could leave. This

was important because patients detained under the Mental Health Act could only leave with the

correct authorisation. Others were informal that meant patients were free to leave the ward at any

time. Patients told us they knew about how to leave the ward. All wards had “green rooms” which

were quiet, low stimulus rooms that staff kept locked and used for de-escalation. The garden

areas for each ward were open during the day. The service adhered to the trust smoke free policy

and patients could not smoke on site. Staff offered smoking cessation advice and nicotine

replacement therapy to support patients who smoked.

The service also had a trust agreed restricted items list which applied to everyone. This included

items such as cigarettes lighters, matches, knives or other sharp objects/weapons, illicit

substances and alcohol. Staff did not routinely search patients for these items but asked if patients

had any of these items in their possession. Staff kept any restricted items in a secure place and

returned them to patients when they left.


The trust reported there were 27 incidents of restraint and no incidents of seclusion between 1

March 2017 and 28 February 2018.

Nineteen of the 27 uses of restraint were within the last 3 months of the reporting period. In

February 2018 there were 11 restraints (on one service user) in Forest Close Bungalow 2

(Female). There were also eight uses of rapid tranquilisation in this month in Forest Close

Bungalow 2.


The below table focuses on the last 12 months’ worth of data: 1 March 2017 and 28 February

2018.


restrained


prone restraint

Rapid

tranquilisations

Forest Close

Bungalow 2 0 17 7 0 (0%) 8

Forest Close

Bungalow 1 0 6 3 0 (0%) 0

Forest Close

Bungalow 1A 0 3 2 0 (0%) 0

Core service

total 0 27 13 0 (0%) 8

There were no incidents of prone restraint.

There were no instances of mechanical restraint over the reporting period.

There were no instances of long term segregation over the 12-month reporting period.

The service participated in the trust restrictive interventions project group to support wards to

become safe places for patients and staff. This was a trust wide agenda to implement safewards

interventions as a part of service improvement and safety agendas. In October 2017, the trust

awarded the service recognition of full implementation of all the safewards interventions.

Staff were knowledgeable about safewards interventions and reducing restrictive practice and

aimed to support patients in the least restrictive way without compromising safety. The staff team

on one ward worked together using reflective practice, formulation and debriefs to understand and

validate one patient’s experiences when they were struggling with their mental health. This

showed determination to use alternatives to restraint and their interventions significantly reduced

the number of incidences of restraint with this patient.

Staff rarely used restraint with patients but when they did, they offered debriefs with patient. Staff

used this as an opportunity to work in partnership with the patient and make changes that made a

difference to them. We saw one example where staff changed the care plan and named nurse

arrangements in response to the patient’s feedback about their experience. The patient could tell

us how this supported their recovery and had not been involved in further restraint.

All staff received mandatory training called Respect training at different levels according to their

role. This training included physical interventions and breakaway techniques that staff could safely

use with patients. Staff across the service had achieved compliance levels above the trust target

of 80% for all three levels of training. The service had an identified trainer who was training some

staff during our inspection.

The service took part in the trust restrictive interventions reduction programme and staff restrained

patients using the Respect techniques. All staff told us that they rarely used restraint and reported

any restraint as an incident. Staff had reported only one incident of restraint since February 2018.

We reviewed the restraint incident record, the patients care record and discussed the incident with

the patient and ward manager. Staff had fully recorded the incident and the manager reviewed the


incident including debriefs with the patient and staff involved. The manager took the views of

everyone into account and took action to reduce the risk of further incidents. Following the

incident, staff made changes to the patients care. Staff reflected on their practice during

supervision and the patient told us things were much better now.

At our previous inspection in 2016, we found that staff did not always complete physical

observations following rapid tranquillisation in line with the trust policy. Doctors prescribe

medicines for rapid tranquillisation to help agitated or distressed patients. At this inspection in

2018, staff had made the improvements and now consistently followed the trust policy for

administration of rapid tranquilisation, post-administration observations, and incident reviews. At

our previous inspection in 2016, we found that staff did not follow national guidance for sodium

valproate. This is a medicine used to treat epilepsy and should not be prescribed to women of

childbearing age. At this inspection in 2018, no patients were prescribed sodium valproate.

Safeguarding


Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will also be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.


Staff received mandatory training in adult and children safeguarding and knew how to raise and

report safeguarding concerns. Safeguarding training for adults and children was mandatory at

different levels for all staff depending on their role. The service had achieved mandatory

safeguarding training compliance above the trust target for all levels of safeguarding training. The

ward managers were identified safeguarding leads for the service and staff reported all

safeguarding concerns as incidents on the trust electronic reporting system. Ward managers

reviewed the incidents and raised issues with the trust safeguarding team for advice and support

to protect patients. Staff gave examples of when they discussed safeguarding that included

concerns about allegations of financial abuse.

The service followed safe procedures for children visiting. Staff followed the trust child visiting

policy and included information about children visiting in their service information booklet for

patients and relatives. Children did not enter the wards or learning and recreation hub and used a

designated visitor’s area in the “core house”. This was an on-site facility where staff such as

medical and psychology staff based themselves and where staff held meetings.

Sheffield Health and Social Care NHS Foundation Trust had submitted details of no serious case

reviews commenced or published in the last 12 months (1 March 2017 – 28 February 2018) that

relate to this core service.


Staff had access to all the information they needed to deliver care safely. Staff kept all patient

information on a secure electronic system that required individual passwords for access.


Administration staff scanned in any paper documents in a timely way that meant electronic patient

information was readily available and accessible to all staff. Staff shared and recorded essential

information at regular multidisciplinary meetings and during their staff handovers. We observed

two afternoon staff handovers where staff overlapped between the early and late shift. Both

handovers were comprehensive and all staff coming on duty had access to all the information they

needed about all the patients on their ward.


Staff followed good practices in medicines management that included transport, storage,

administration, reconciliation, recording, and disposal. However, staff in all wards did not note the

date of opening for medicines that had a reduced expiry date once in use such as creams, liquids

and an insulin pens. This was not in keeping with the trust medicines management policy. This

stated that ‘staff should ensure they take note of all advisory and cautionary labels and information

supplied by the pharmacy with the product’. The policy only specifically mentioned eye drops and

ointment as requiring a date of opening.

Staff completed the electronic prescription and administration records to show that people

received their medicines as prescribed. Staff said they received good pharmacy support and the

supply process ensured medicines were always available for patients. Non-medical nurse

prescribers attended all multidisciplinary meetings and met with patients.

The wards received support from clinical pharmacists and pharmacy technicians. The clinical

pharmacists attended multidisciplinary team meetings and regularly reviewed prescribing. The

wards had a patient-centred approach to medicines optimisation and patients told us they were

involved in decisions about their medicines. The pharmacist and non-medical prescriber held a

monthly informal drop-in session where patients could discuss their medicines.

Staff demonstrated a patient-centred approach through encouraging and supporting patients’ self-

administration of medicines. The staged process promoted independence whilst making sure

people were safe. However, we noted that the trust self-administration of medicines policy was

due for review in October 2015 and was therefore out of date at the time of our inspection.

Doctors reviewed the effects of medicines on patient’s physical health at least yearly, especially

when the patient was prescribed a high dose of antipsychotic medicine. Staff did a monthly audit

to identify patients on high dose or multiple antipsychotic medicines and reviewed prescribing at

the fortnightly multidisciplinary meeting.

At our previous inspection in 2016, we raised concerns that staff didn’t consistently monitor

patients’ physical health when they were prescribed Clozapine. This drug is used to treat patients

who do not respond well to other antipsychotic drugs. It has a number of potential side effects and

close medical supervision must take place because of the risk of side effects. We told the trust it

must ensure that medicines are managed safely and where required, physical health monitoring

and observations are carried out by staff. At this inspection, we found that staff had made the

improvements and now always followed the trust guidelines for Clozapine monitoring. However,

we noted that the trust guidelines for Clozapine were dated February 2014 and did not have a

review date. The guidelines did not guide staff on all the requirements for monitoring patient

parameters during long-term treatment with clozapine. For example, four to six monthly monitoring

of fasting blood glucose levels in line with the British National Formulary. We looked at six records


for people prescribed clozapine. Three people out of the six did not have a fasting blood glucose

result in the previous six months. Further evidence submitted by the trust demonstrated that 30%

of patients had not had the required blood tests.


Providers must report all serious incidents to the Strategic Executive Information System (STEIS) within two working days of an incident being identified.

Between 1 March 2017 and 28 February 2018 there were no STEIS incidents reported by this core service.

A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.

We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system also included no serious incidents relating to this core service.

Although there were no serious incidents about this service, managers informed staff about

lessons learned from other areas within the trust. The trust governance systems and processes

shared information about serious incidents and managers cascaded relevant information at team

meetings. Managers distributed team meeting minutes so that staff who were not present knew

about relevant safety issues.

Staff gave an example of changing their practice with one patient following incidents that involved

restraint and rapid tranquilisation. As a result, there was a significant reduction in the use of

restraint and rapid tranquillisation. Staff shared this information with other wards for their learning.


The Chief Coroner’s Office publishes the local coroners’ Reports to Prevent Future Deaths which all contain a summary of Schedule 5 recommendations, which had been made, by the local coroners with the intention of learning lessons from the cause of death and preventing deaths.

In the last two years, there were no ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.

The service had a thorough system for reporting and reviewing incidents. All staff knew how to

report incidents through the electronic incident reporting system and managers reviewed the

incidents. We reviewed a range of incidents that staff reported such as verbal abuse and

medication related errors that senior staff discussed at their local monthly governance meeting

and ward meetings. Staff demonstrated their duty of candour about one incident of restraint with a

patient. The Duty of Candour regulation is in place to ensure that providers are open and

transparent with people who use services. It also sets out some specific requirements that

providers must follow when things go wrong with care and treatment, including informing people

about the incident, providing reasonable support, providing truthful information and an apology

when things go wrong.

The ward had a range of opportunities for staff and patients to de-brief following any incidents.

This meant that staff and patients had opportunities to receive additional support following

incidents. This included discussion at the multidisciplinary meeting, one to one support with the

ward manager, and weekly team reflection. We observed one staff reflective practice session

where any member of staff could attend. Staff had open and honest discussions about things

happening in the service that affected them.




We reviewed 13 electronic care records across the service. Staff kept all 13 records up to date

with evidence of risk assessment and management plans and timely reviews. All 13 involved

patients and considered their views. This was an improvement staff made following the Mental

Health Act Reviewer visits in 2017. The service had an individualised and holistic approach to

assessing, planning, and delivering care and treatment. Staff used a clear rehabilitation and

recovery pathway that commenced when the service received a referral. The multidisciplinary

team held weekly referral meetings, discussed new referrals to the service, and agreed their follow

up action. Two members of the team carried out a pre-admission assessment and planned

admissions with patients who were appropriate for the service. Staff worked together with patients

and other teams to support patients and their families. This included pre-admission visits and

providing written information about the ward.

Staff updated patient care records on the day of admission. This included risk assessment and

management plans, care plans and physical health assessments and monitoring. All three wards

had the necessary equipment to carry out physical health examinations. Nurses and support

workers carried out physical health checks with patients and the service employed one nurse who

took the lead for physical health monitoring. Staff referred patients to other specialist health

services when needed such as speech and language therapy and physiotherapy.

Staff and patients completed and reviewed personalised and recovery orientated care plans

together. Care plans covered a range of needs that included physical, mental health and social

needs. The service used collaborative care planning and the recovery model to set meaningful

patient-centred goals. Each care plan indicated how much involvement patients wanted in their

care plan. This five point coloured scale allowed patients to choose from “I would prefer not to be

involved in the process at the moment” through to “I am very keen to work on my goal. I keep

working on my goal and practice the steps with very little input and support from staff”. Staff asked

patients if they wanted a copy of their care plans and patients had copies if they wanted to keep

them. Patients and relatives told us they were aware of their care plans and goals for recovery.

Staff invited patients and their families to attend regular multidisciplinary meetings to discuss their

care and treatment. Care coordinators from community teams attended meetings that meant

everyone worked together to support individual patients ‘recovery.


Staff used a range of interventions supported by best practice guidance. The service used the

rehabilitation standards set by the Royal College of Psychiatrists and conducted peer reviews to

measure their progress.

The service used the care programme approach framework to ensure that patients received care

and treatment in an organised way. All patients had a care coordinator identified within the

community teams. The wards worked with the community-enhanced recovery teams to support

patients’ timely discharge and reduced the need for hospital in-patient treatment. The service

supported individual patient needs such as arranging gradual discharge and short- term

admissions to support patient’s crisis plans in the community.


The service employed psychology staff who worked across the wards. Psychology staff

received specialist training in using an approach called Reinforce Appropriate, Implode

Disruptive, recognised by the Association of Psychological Therapies. Psychology staff offered

and provided individual psychological therapies with patients where needed. They also

provided psychology support to the wider staff team. This included weekly staff reflective

practice sessions and formulation meetings. These meetings allowed the multidisciplinary team

to gain a shared understanding of individual patients and discuss psychological and psychiatric

approaches to their care and treatment. Staff gave us examples of how this supported their

clinical practice such as reducing restrictive practices. Psychology staff also facilitated a regular

carers support group for relatives and carers of patients who used the service.

At our previous inspection in 2016, we raised concerns that the service offered limited activities

that focused on rehabilitation. At this inspection in 2018, the service had improved access to

rehabilitation-focused activities and developed a recovery college at the learning and recreation

hub. The college reflected recovery principles and offered a range of courses to improve physical

health and wellbeing, life skills, and education and work opportunities. It also had links with other

partners and organisations in the community. Patients gave positive feedback about the college

but commented they would like more opportunity to learn computer skills. The service offered

activities over seven days per week that included art and music therapy sessions facilitated by

sessional therapists.

Staff used outcome measures to monitor patients’ progress. In October 2017 the service introduced a recognised recovery focused patient reported outcome measure called Recovering Quality of Life. Staff asked patients to complete the tool on admission and at their care programme approach review and on discharge. Occupational therapy staff used a recognised outcome measurement called the Model of Human Occupation Screening Tool. Occupational therapists used this tool to measure changes in patient’s recovery over time. However, occupational therapy staff were not fully using the tool on two of the three wards. The service had identified this issue in their accreditation action plan for improvement.

Staff followed best practice guidance for medicine in accordance with National Institute for Health

and Care Excellence medicine optimisation guideline (NG5). Nurses carried out ordering, storage,

and administration of controlled drugs in accordance with the Misuse of Drugs Act 1971 and the

associated regulations. The service completed treatment consent forms for detained patients in

accordance with the Mental Health Act 1983. Staff knew about good medicines practices and the

risks associated with medicines such as antipsychotics and Clozapine. These drugs can cause

serious side effects that affect physical health. This was important because some patients needed

long-term treatment for their mental health condition and could be at risk of developing physical

health conditions. Staff used a recognised side effect monitoring tool called the Liverpool

University Neuroleptic Side Effect Rating Scale. Staff documented when they completed physical

health tests such as blood tests, weight, and body mass measurements.

The service offered a range of interventions to help patients improve their physical health. The

dietician offered patient activities that related to diet and healthy eating on a weekly basis. This

was important because some patients had physical health conditions such as diabetes and others

needed support with weight management. Nurses provided smoking cessation advice and offered

nicotine replacement therapy to patients who smoked. The service had links with substance


misuse teams and offered advice to patients with issues relating to substance misuse such as

drugs and alcohol.

Staff supported patients to find helpful strategies to support their recovery and offered patients a

range of self-help materials to support their mental health and well-being. This included

information about anxiety management and mindfulness, hearing voices, self-harm and

depression.

This core service participated in eight trust wide clinical audits in the 12-month period leading up to

the submission of the provider information return. During the inspection visit, we also found that

the service regularly took part in a range of audits across all three wards. This included audits of

adherence to the Mental Health Act, physical health, clinical records, and clinic rooms. The

governance officer supported the service with the audit process and ensured that staff collected

data in a timely way. The managers had oversight of the completeness of audits and took action

where things needed to improve. We reviewed weekly audits of nursing records and the action

taken by managers in response.


completed


audit

Collaboration

with Primary

Care Clinicians

Service users

on CPA

Provider









solution.

Record keeping


Provider




staff on use of



relevant policy.

Audit of risk

assessments

2016/2017

Trust wide Provider

wide Clinical audit March 2017

Local action plans to

address identified issues.




in 2017/18.

Audit of risk

assessments

2017/2018

Trust wide Provider


Audits of care

plans Trust wide

Provider

wide Clinical audit

January

2018


small scale audits.


teams.

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG43

Transition from

children’s to

adults’ services

Trust wide Provider


Findings fed into






transitions


for young

people using

health or social

care services

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG13

Workplace

health:

management

practices

Trust wide Provider

wide Clinical audit

September

2017



future

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG58

Coexisting

severe mental

illness and

substance

misuse:

community

health and

social care

services

Trust wide Provider

wide Clinical audit

December

2017

Action plan under

development


Patients had access to a range of specialists within the multidisciplinary team to support their care

and treatment. This included qualified mental health nurses, support workers, medical staff,

psychology and occupational therapy staff, activity support workers and administration staff. The

service also had access to pharmacy staff, art and music therapy staff and a dietician. The ward

worked closely with the community enhanced recovery team to support patients’ recovery and

discharge plans.

Managers ensured that any new staff to the wards received a local induction. This included any

student nurses on placement in the service. The induction was consistent across all three wards

that meant that when staff moved across the service they were already familiar with some systems

and processes.

The trust’s target rate for appraisal compliance was 90%. All teams within this Core Service met

this target. As at 31 January 2018, the overall appraisal rates for non-medical staff within this core

service was 99%.

Ward name

Total number of


staff requiring an appraisal

Total number of


staff who have had an

appraisal

% appraisals


Ward name

Total number of



Total number of



appraisal

% appraisals

Forest Close Bungalow 1 25 25 100%

Forest Close Bungalow 1A 28 28 100%

Forest Close Bungalow 2 25 25 100%

Forest Close Central 31 32 97%


Trust wide 1440 1495 96%

The trust’s target rate for appraisal compliance was 90%. As at 31 January 2018, the overall

appraisal rates for medical staff within this core service was 100%.

Ward name

Total number of



Total number of

permanent medical


appraisal

% appraisals

Forest Close Central 2 2 100%



During the inspection, we checked the appraisal arrangements for all staff on the wards and found

there were good arrangements in place. Managers ensured they supported the professional

development of staff through the trust appraisal process. The clinical nurse manager had oversight

of an appraisal matrix which included the arrangements for all staff and we saw examples of

completed records of staff appraisal. Appraisal identified any performance issues and specific

training needs.

Staff received additional specialist training appropriate to their roles such as positive behaviour

support, motivational interviewing, recognising and assessing medical problems in psychiatric

settings, and clinical skills training such as taking blood, electrocardiograms and early warning

scores. Two nurses had completed their non-medical nurse-prescribing course and two nurses

were completing a postgraduate certificate for recovery in mental health. These were all good

examples of how the appraisal system supported staff professional development to improve the

care the ward provided.

The trust’s measure of clinical supervision data was the number of sessions delivered.

Between 1 March 2017 and 28 February 2018, the average rate across this core service was 88% for non-medical staff compared to the trust’s target of 66%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide.


sessions required


sessions delivered


rate (%)



sessions required


sessions delivered


rate (%)

Forest Close 321 281 88%



During the inspection, we checked the clinical supervision arrangements for all three wards to

understand the information the trust provided. All three wards had good arrangements for clinical

supervision. This was an improvement from our previous inspection in 2016 because we told the

trust it must ensure that the service complied with the trust supervision policy.

Managers made sure that all staff received clinical supervision according to the policy. The clinical

nurse manager had access to an electronic database of the clinical supervision arrangements

across the service from across the trust. Nursing staff cascaded responsibilities for supervision,

which meant that band seven nurses supervised band six nurses through to band five nurses who

supervised support workers.

Psychology, occupational therapy, and medical staff also had supervision arrangements in place.

Managers raised any performance issues that involved bank and agency staff through the trust.

As well as formal clinical supervision, the ward team met on a regular basis to discuss and reflect

on patient care. This included reflective practice sessions, handovers, and debriefs. Staff told us

they felt well supported in their roles.

Managers used supervision and the trust disciplinary process to deal with any poor staff

performance promptly and effectively. Where managers identified issues with staff performance

they set and reviewed performance targets. We reviewed how managers used supervision to

improve staff performance and saw examples with targets for improving standards for record

keeping and collaborative care plans.

Multidisciplinary and interagency team work

The ward teams had effective working relationships with one-another and other professionals

involved in patient care.

The multidisciplinary teams held weekly meetings on all three wards to discuss patients care and

treatment. We attended one multidisciplinary meeting during the inspection. Staff kept

comprehensive records of the meeting. Staff invited patients and their carers to attend and

everyone had the chance to give their views. If patients did not want to go to their meeting, staff

spoke with them afterwards to provide feedback.

Staff invited other external professionals and members of the community teams to these

multidisciplinary meetings as appropriate. The teams had good working relationships with each

other and shared relevant information about patient needs. At our previous inspection in 2016, we

raised concerns that most patients did not have an identified care-coordinator from the community

teams. We told the trust that it should ensure that patients were allocated a care coordinator from

an appropriate community based mental health team. At this inspection in 2018, this had improved

and all patients had appropriate care-co-ordination in place. Members of the community teams

also visited patients on the ward and provided interventions as part of their care and treatment

plans.


The service had well-established relationships with local housing providers that meant they could

support patients’ discharge to independent tenancies. The team on one ward worked closely with

one organisation to support a patient’s discharge to the community. This was important because

the patient had been in hospital for a longer than expected length of stay and everyone involved

wanted the discharge to be successful.

Staff held handovers at every shift change and discussed each patient. We observed two effective

staff handover meetings from the early to the late shift. The handover nurses provided

comprehensive and up to date information about each patient. This included information about

physical and mental health needs, leave arrangements and medication changes. Staff on day

shifts had 10-minute handover time with night staff. We did not observe these handovers, but staff

from all three wards spoke about how these meetings were less effective. One staff member told

us that the night-time handovers could last for up to 30 minutes; one told us that there was not

enough time and another said handovers started before all staff on shift were present.


Practice

As of 28 February 2018, 92% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training was mandatory for all core services for inpatient and all community staff and renewed every three years.

As well as mandatory training, some qualified nurses had completed Mental Health Act

competency framework training to enhance their knowledge and understanding of the Mental

Health Act.

At the time of our inspection, there was a mixture of informal patients and patients detained under

the Mental Health Act across the service. All three wards had a locked entry and exit system that

meant patients could not leave the ward without staff to help them. All wards displayed a notice to

tell people how they could leave the ward freely. This was important because some patients were

informal and these patients told us they knew how they could leave the ward.

The wards had access to administrative support and advice about the Mental Health Act and staff

accessed the trust policies and procedures on the trust intranet. Staff had good understanding of

the Mental Health Act and how to get additional support and advice. They carried out regular

audits as part of the trust audit programme that included their adherence to the Mental Health Act.

We saw evidence that that all wards completed Mental Health Act Audits as needed by the trust.

The service governance officer had oversight of compliance with the Mental Health Act and

managers ensured that staff took any actions to improve compliance. This included making sure

patients understood their rights under the Mental Health Act.

All wards displayed information for patients about the independent mental health advocacy

service. Staff knew how to access the advocacy services and advocates visited the wards on a

regular basis. They could attend multidisciplinary meetings to support the patient’s voice and

patients told us how an advocate supported them.

All wards displayed other information about the Mental Health Act in patient areas. The information

was well organised and accessible. In addition, staff gave all patients the service welcome booklet

that contained helpful information about section 17 leave arrangements, legal support, and

advocacy services.


The Mental Health Act Reviewer inspected the service in January 2017 and July 2017 and raised

a number of concerns following each visit. This included; blanket restrictions around locked

sensory rooms, issues with section 17 leave forms, lack of evidence of risk management plans,

and issues with patient and carer involvement in care plans. During this inspection in 2018, we

saw that the wards had made improvements that addressed all these concerns. All wards had a

clear process to identify and review blanket restrictions. Staff identified the locked doors, which

were identified as trust-approved restrictions. We checked section 17 leave forms and found them

to be in good order. Staff reviewed section 17 leave arrangements at multidisciplinary meetings.

They crossed out old section 17 leave forms that ensured staff could easily identify the most up to

date form and shared copies with patients and their carers. This was important because detained

patients need the right legal authority to be in place before they leave the ward. We examined 13

care records and all had evidence of patient views and carer involvement where appropriate.

Staff supported patients to take their section 17 leave, however, two carers told us that sometimes

staff cancelled section 17 leave at short notice. Staff told us they always facilitated section 17

leave providing the patient was well enough to leave the ward.

Staff asked patients for their consent to treatment and used second opinion appointed doctors

when needed. Staff ensured that all T2 and T3 forms were correct and up to date. These forms

give staff legal authorisation to administer certain medications to detained patients.


As of 28 February 2018, 99% of the eligible workforce in this core service had received training in

the Mental Capacity Act level 1 and 98% had received training in the Mental Capacity Act level 2.

The trust stated that this training was mandatory for all core services for inpatient and all

community staff and renewed every three years.

Staff had a good working knowledge of the Mental Capacity Act and its principles. Staff assumed

patients had capacity unless indicated otherwise. They knew that capacity assessments were

necessary for specific decisions such as discharging patients to alternative placements. Staff

documented their decisions about capacity on the patient’s electronic record. Staff always gained

patients’ consent and encouraged patients to make decisions for themselves such as setting their

goals and what activities they wanted to do. Staff had access to administrative support and advice

about the Mental Capacity Act and accessed the trust policies and procedures on the trust

intranet. We did not see any evidence that staff carried out audits in relation to the Mental

Capacity Act.

The trust told us that no Deprivation of Liberty Safeguard applications were made to the Local

Authority for this core service between 1 March 2017 and 28 February 2018.

CQC received no direct notifications from Trust between 1 March 2017 and 28 February 2018

relating to this core service.

At the time of our inspection, no patients were subject to Deprivation of Liberty Safeguards.




We offered all patients in the service the opportunity to speak with us, and seven patients spoke

with us. We held one focus group and left comments cards for patients to provide further feedback

to us about their experience of the service. The feedback we received from patients was overall

positive about the way staff treated them

Patients and carers had strong relationships with staff who were caring and supportive. The

managers of the service supported a culture of working in partnership with patients and their

carers. The clinical nurse lead attended every multidisciplinary team meeting and knew individual

patients well.

All patients described staff as kind, caring and respectful. Patients described staff as “wanting the

best for them” and “wanting to get me better”. Carers reported feeling the staff were consistent and

shared “a common goal” to help people recover. We observed that staff were respectful and

responsive to individual patient’s needs and took time to ensure patients with communication

needs understood information. Staff respected patients’ privacy and dignity by knocking on

bedroom doors before entering. All staff knew patients well and supported them to maintain their

independence and relationships with people who were important to them. This included daily living

skills, self-medication, and support to access individual cultural, social, and religious preferences.

Staff directed patients to other services to support their recovery. For example, the recovery

college linked patients with activities in the local community and patients attended groups such as

weight management and sports activities. Staff went with patients if necessary as part of the

patient’s recovery plan.

Staff maintained the confidentiality of all information about patients across all three wards. Staff

stored electronic information about patients in a secure system and made sure that information

displayed in ward offices was always kept confidentially.

Patient led assessments of the care environment are undertaken by local people visiting services

and assessing the care environment. The 2017 Patient-led assessments of the care environment

(PLACE) score for privacy, dignity and wellbeing at the core service location was higher than

similar organisations.

Site name Core service(s) provided Privacy, dignity and

wellbeing

Forest Close MH - Long stay/rehabilitation mental health wards for

working age adults 100%

Trust overall 96.6%

England average (mental health and

learning disabilities) 90.6%

Involvement in care

Staff involved and encouraged patients and their carers where appropriate to be involved in their

care. Patients and their families told us about how they were involved and knew what was

happening for example about discharge plans.



Nurses used the admission process to show patients around the ward and gave them a welcome

information booklet that explained about the service and information about collaborative care

planning. Housekeeping staff spoke with patients to make sure the service provided individual

dietary preferences food in keeping with their cultural needs such as halal food. Patients told us

they felt welcomed to the ward and had opportunity to look around.

Staff recognised and respected all patients’ needs, and reflected this in the way staff delivered

care. This included patients’ cultural, religious and communication needs. Staff involved patients in

their care planning at a level they chose. Patients had copies of their care plans and risk

assessment plans if they wanted to keep them. Staff supported patients to think about what

activities and therapies would be helpful for their recovery and devised weekly activity schedules

with patients. Staff involved patients in decisions such as which day during the week they would

prefer housekeeping staff to deep clean their room. All three wards had ways to collect patient

feedback about their experience on the ward. Staff were committed to continually improving their

service. They asked patients to complete surveys and had increased the frequency of patient

community meetings from fortnightly to weekly. Staff persevered to encourage patients who were

less motivated to attend these community meetings and ensured that community-meeting minutes

were accessible on the ward. We reviewed minutes of community meetings held on the wards and

saw evidence that staff invited patients to be involved in decisions about the service such as what

activities and therapies to provide. Patients told us they felt they had enough opportunity to be

involved in ward decisions.

The service invited patients to be involved in the recruitment of staff. They formed an informal

panel and gave feedback to staff based on their conversations with candidates. The clinical lead

told us that the recruitment panel took patient views seriously when considering recruitment of

appropriate staff.


We spoke with four carers of patients who used the service. Overall, they gave positive feedback

about the support and information they received from ward staff. They were positive about the

care and support that staff offered to them and the patient. Carers told us that this was “the best

service” in terms of progress for their relative. We saw that relatives visited during our inspection

and attended care programme approach meetings.

The wards routinely gathered and shared feedback from carers about their experiences of the

service. This included a questionnaire that staff completed with carers and included their views

about involvement. We reviewed carer’s feedback from one ward and saw that overall it was

positive about their level of involvement and support from staff.

The service recognised that carers were a big part in helping patients care and recovery and staff

sought patients’ consent to involve their families. Staff gave carers information about how to

access carer’s assessments if they more needed help and advice. They offered access to a carers

support group both on and off site, facilitated and attended by staff from the service. Carers told us

they had attended the carers’ group meetings and “family days” that they found helpful.




Bed management

The trust provided information regarding average bed occupancies for three wards in this core

service between 1 March 2017 and 28 February 2018.

Two of the wards within this core service reported average bed occupancies ranging above the

provider benchmark of 85% over this period in all of the 12 months. Forest Close 1 had an

average bed occupancy rate of less than 85% for January and February 2018.

We are unable to compare the average bed occupancy data to the previous inspection due to

differences in the way we asked for the data and the time period that was covered.

Ward name Average bed occupancy range (1 March 2017 – 28


Forest Close Bungalow 1 74.6 – 114.5

Forest Close Bungalow 1A 93.3 – 101.4


At the time of our inspection, all three wards had vacancies. When patients went on leave, they

always had their bed available when they returned to the ward. All patients were from the trust

catchment area with no patients currently out of area waiting to use the service.

The service reconfigured approximately three years ago and managers were considering an

options appraisal to maximise bed use and meet the rehabilitation demands of the local

population.

The service held joint referral meetings with the community enhanced recovery team. Staff

discussed how best to provide care to meet the patients’ needs which could include community

services rather than hospital admission. Senior ward staff reviewed referrals and then planned

appropriate admissions.

The trust provided information for average length of stay for discharged patients for the period 1

March 2017 to 28 February 2018.

We are unable to compare the average length of stay data to the previous inspection due to

differences in the way we asked for the data and the time period that was covered.

Ward name Average length of stay range (1 March 2017 – 28



Forest Close Bungalow 1A 2.0 – 2155.0


At our previous inspection in 2016, we raised concerns about the excessive length of stay for eight

patients. We told the trust it should ensure that patients were discharged to placements that were


more appropriate. At this inspection in 2018, six of those eight patients had moved on to other

placements. Staff told us the average length of stay was up to 18 months and we examined the

care records to understand why the remaining two patients had not moved on. Both patients had a

clear discharge plan and staff provided interventions to support their recovery.

This core service reported no readmissions within 28 days between 1 March 2017 and 28

February 2018.

This core service reported 17 out area placements between 1 March 2017 and 28 February 2018.

As of 1 March 2018, this core service had seven ongoing out of area placements.

Due to inconsistencies in the presentation of the data it is not possible to calculate a range for the

length of the out of area placements. There were no placements that lasted less than one day.

All of the 17 out of area placements were to ‘place a patient with another provider due to this

better suiting their care or personal needs’.

Number of out of area

placements

Number due to specialist

needs Number due to capacity

Number of ongoing

placements

17 17 0 7


Between 1 March 2017 and 28 February 2018 there were 26 discharges within this core service.

This amounts to 3% of the total discharges from the trust overall (804).

The trust has advised that during this time there were 62 delayed discharges within this core

service. Due to the way the data is recorded by the trust, patients whose discharge was delayed

by more than one month may appear multiple times within this total.

However, during the inspection visit, we checked how many patients the service had identified as

a delayed discharge. Managers told us there were no delayed discharges.

Staff used the care programme approach to ensure that patients had a smooth transition to

appropriate placements on discharge. Staff held discharge meetings with patients, carers and the

community providers so that everyone was prepared for the discharge arrangements.

The clinical nurse manager attended a local funding panel meeting to advocate for patients

complex housing and support needs in the community. The impact of this meant that the service

had agreed funding and created a bespoke care package for one patient who had been in hospital

for a long time. The package included support to recruit the right staff to support the patient’s

needs and provide out-reach from the ward to support a successful discharge. During the

inspection, staff supported this patient to visit the placement.

Staff supported patients during referrals and transfer between services. Staff only moved patients

to another ward if they could no longer meet their clinical needs such as when patients needed

more intensive care. Staff said they could quickly find an appropriate bed on another ward and told

us how they continued to support one patient who had moved quickly to another ward in the trust.



All patients had their own bedrooms with fitted furniture and ensuite bathroom facilities. Patients

personalised their bedrooms with their belongings. All patients had a key for a lockable drawer and

had safes in their bedrooms. This meant that patients had somewhere to store their possessions

securely. All patients we spoke with liked their bedrooms and told us that bedrooms were

comfortable and clean. Staff had arranged for one patient with specific needs to access a larger

room and bathing area with adequate space for everything they needed.

The wards were compact but had enough space to promote the comfort, dignity, and privacy of

patients. Visitors used a communal space in the ‘core house’ and the café area adjacent to ward

one A. The ‘core house’ was a separate building on site used by staff for offices and meeting

rooms. Carers commented they were happy with the visiting facilities but would prefer the choice

of more comfortable seating in the café area.

Patients had access to a communal lounge, beverage facilities, laundry, dining areas, and

pleasant garden spaces on the wards. The wards were comfortable and well maintained and staff

involved patients in choosing fabrics and furnishings. The only quiet space was the “green rooms”

that staff kept locked and used for de-escalation. However, patients could use their bedrooms at

any time as a quiet space. Bedrooms had pictorial screening on the door windows to promote

privacy and confidentiality that patients could control from inside. Patients had access to other

shared spaces off the ward. This included the café area on ward one A, as well as the recreation

and learning hub.

Patients could have access to their personal mobile phones and electronic devices. Where

patients did not have their own phone, the ward provided use of a ward phone and two public

telephones so that patients could maintain contact with others. We observed that the public phone

on bungalow one A was situated in a corridor outside the ward area and did not afford much

privacy. This was because it was close to the busy reception area where people entered and left

the ward.

We observed lunchtimes as sociable and relaxed times. Lunchtimes were protected times that

meant patients could eat their meals without disturbance from other things such as meetings.

Patients could self-cater but housekeeping staff also prepared food on site. The trust delivered

specialist foods to the wards depending on patients’ specific dietary or cultural needs. The wards

displayed a daily menu choice that was on a four-week rota. Housekeeping staff offered

alternatives to patients if they did not like the options available. Patients and staff regularly

discussed the meal choices at community meetings. Patients had access to drinks and snacks at

all times of the day and gave overall positive feedback about the food quality and the opportunity

to self-cater.

Patient led assessments of the care environment are undertaken by local people visiting services

and assessing the care environment. The 2017 Patient-led assessments of the care environment

(PLACE) score for ward food at the location scored higher than similar trusts.


Forest Close MH - Long stay/rehabilitation mental health wards for

working age adults 98.9%

Trust overall 96.4%

England average (mental health and learning disabilities) 91.5%



Staff encouraged patients to be active within their local community. Patients had a seven-day

activity plan that included leave and activities in the community. This included educational,

vocational, and volunteering opportunities via the recovery college. Patients who used the

recovery college thought it offered them excellent opportunities for recovery. Managers planned

staffing requirements at their daily service-planning meeting so that patients could have leave if

they needed staff to support them. Identified staff had access to trust transport and acted as

designated drivers to take patients out as part of their care and treatment plan. Patients told us

they enjoyed activities in the community

Staff supported patients to maintain contact with their family and carers. The wards had mealtimes

as protected times but otherwise carers had open access to visit their relatives. We saw that family

contact took place and patients went out with their families.


All three wards and the learning and recreation hub were situated in bungalows and were

accessible for people with mobility needs. All three wards had accessible communal bathing

facilities that patients used with staff support if they needed more help. We observed these

facilities did not have screening in the room to protect patients’ dignity.

Staff completed falls assessments on admission and referred patients to the physiotherapy service

for specialist assessments and equipment when they needed their advice.

Throughout all three wards, we saw information displayed to support patients such as how to

complain, how to contact the advocacy service and the Care Quality Commission.

Staff could access information from the trust in easy read, other languages, and formats to suit

individual patient communication needs. Staff told us they knew how to access interpreters and

signers through the trust system. We observed how staff communicated with patients with specific

communication needs. When we reviewed the care records, we saw clear evidence of the specific

support and adaptations that staff used after working together with the learning disabilities team.

This included a pictorial weekly activity planner, extra involvement from the community enhanced

recovery team and positive behaviour support plans.

The wards referred to a speech and language therapist and had regular involvement from a

dietician. Staff worked closely with housekeepers to ensure that patients had access to food that

met their dietary and religious needs.

Although the wards did not have a designated multi-faith area, patients accessed a multi-faith area

at the recreation and learning hub. Maintenance staff were re-furbishing this room at the time of

our inspection. Staff considered patients’ spiritual and cultural needs as part of their assessment

and supported patients to meet these needs. Staff supported patient to attend religious services of

their choice and facilitated visits from faith representatives.


This core service received two complaints between 1 March 2017 and 28 February 2018. One of

these was not upheld and the other was still under investigation.

Ward Total Fully Partially Not Under Referred to Upheld by


name Complai

nts

upheld upheld upheld Investigation Ombudsman Ombudsman

Core

House 1 0 0 0 1 0 0

Bungal

ow 2 1 0 0 1 - 0 0

When we spoke with patients and their carers, they told us they had no complaints about the

service but knew how to make a complaint and would feel confident to do so. Staff knew how to

deal appropriately with concerns and complaints raised by patients or relatives. They directed

patients to the trust corporate affairs team that managed complaints. Staff listened to patient

complaints at ward community meetings and tried to deal with issues as they arose.

At the time of our inspection, the clinical nurse manager told us that no complaints were under

investigation. The two complaints reported by the trust had not been upheld. Senior managers

discussed any complaints at their monthly governance meetings and feedback relevant

information to ward staff through team meetings.

This core service received six compliments during the 12 months from 1 March 2017 to 28

February 2018 which accounted for 1% of all compliments received by the trust as a whole.



Leadership

The leadership and governance arrangements and the culture at Forest Close promoted high

quality patient-centred care across the service. The clinical nurse manager was the most senior

nurse on site and was clear about their role. The clinical nurse manager was highly visible to staff

and patients and knew the service well. They received supervision from a senior operational

manager and were supported by a range of clinical and non-clinical staff on site. Senior staff had

the skills, knowledge, and experience they needed for their roles. Most had worked at the trust for

many years and had opportunities to develop their leadership and management skills. They had

been involved in the service transformation that began three years ago and could explain how the

service had progressed during that time. They had a shared vision for future developments and

improvements to the service. We visited all three wards and found that managers applied

consistent governance structures and staff felt well supported.

Vision and strategy

Managers and staff knew and understood the trust’s vision and values. The trust vision and

strategy was highly visible and accessible across the site. The service displayed a directorate

mission statement that reflected the trust vision and values and a culture of recovery. When we

spoke with staff and observed interactions with patients and each other, we saw how staff upheld

values of respect and compassion.

Managers had a clear vision for improvements to the service. Staff had reviewed their journey

from transformation three years ago and managers were beginning to think about future service

developments to meet local need.

Staff provided high quality care within the budgets available to them. Staffing levels across the site

had improved since our previous inspection in 2016. Managers reviewed staffing requirements,

thought about succession planning, and had fully recruited to all vacancies. Although some staff

we spoke with wanted more staff available on the wards, they did not report any effect on patient

safety or care due to financial restraints.

Culture

Staff shared a culture where they felt valued and supported and enjoyed coming to work. Many

staff had worked within the service for a number of years. They felt that changes to the service,

although difficult at the time, had definitely improved things for patients. Clinical and non-clinical

staff felt very positive and proud about the work they did to support patients’ recovery.

Staff felt confident to raise concerns because they worked within a supportive culture. They felt

managers were approachable and would listen to them. They knew how to raise the

whistleblowing process and some knew about the role of the freedom to speak up guardian. This

is an independent role that supports staff to speak up which trusts were asked to have in place

since October 2016.

During the reporting period, there was one case where staff had been either suspended, placed under supervision, or were moved to a different ward. One grade 3 member of bank staff had been suspended.



Ward name Suspended Under supervision Ward move Total

Forest Close 1 0 0 1


Managers felt comfortable dealing with poor staff performance when they needed to. They referred

to trust polices and used management supervision to improve performance. Managers felt

supported by the trust human resources and occupational health departments. At the time of our

inspection, two staff were suspended from one ward while under investigation. The ward manager

told us these incidents were not directly associated with care on the ward at Forest Close.

Ward teams worked well together to promote the delivery of safe and high quality care. Sickness

levels across the service were below the overall trust level and remained similar to when we last

inspected the service. Managers increased the level of support available to staff during times of

increased difficulty such as when caring for highly distressed patients. This included more frequent

team meetings and opportunities for reflection. This was important so that staff felt supported and

could remain resilient.

Managers offered staff the opportunity to discuss their career and personal development at their

supervision and yearly appraisal. Managers used this information to support appropriate specialist

training needs to improve staff knowledge and skills and career progression.

The trust recognised contributions made by staff by holding yearly staff awards. Staff were

encouraged to nominate their colleagues in recognition of their contributions. One staff member

had received a trust award in recognition of the work they did to support the service. They were

instrumental in organising fund raising and social events that included staff and patients such as

barbeques and raffles.

Governance

Managers had effective governance systems to monitor the quality and safety of care the service

provided. This meant that the environments were safe and clean, and wards were adequately

staffed with staff with the right skills. Staff assessed and managed risks well. They protected

people from harm and reduced restrictive practices across the wards. The service used good

practice in accordance with national guidelines including National Institute for Health and Care

Excellence to provide evidence based care. Staff treated people with compassion and adhered to

the Mental Health Act and Mental Capacity Act requirements to ensure they protected patients’

rights. The service managed admissions and discharges in a timely and patient-centred way that

meant patients and carers had good experiences of the service.

The service had made all the improvements following concerns raised from the previous

inspection and Mental Health Act Reviewer visits. Staff completed audits and managers generated

action plans and timescales that sustained improvements in the quality of care.

Senior managers and ward staff held regular meetings that shared relevant information with staff.

Senior managers met to review information about performance, quality, and safety. Ward

managers held staff meetings to pass on information and we saw evidence that staff discussed

performance, quality, and safety issues.


The service had a clear care pathway that managers and ward staff understood. This meant that

staff knew how the ward worked with other teams within the trust, wider teams, and external

parties such as educational, vocational, and housing partners.

However, we identified some areas of concern that we felt the service should improve. This

included:

• managers did not have robust systems or processes that ensured staff adhered to the

dress code and infection control policy, and some aspects of medicine management and

medical stock control

• managers could not provide assurance about the completion of safety work at the learning

and recreation hub or that staff always held effective handover meetings

• staff used some trust medicine related policies and guidelines that were not up to date or

had no review date.


The service held a risk register that managers reviewed and updated. The risk register was up to

date and included the issue about the integral alarm system in the learning and recreation hub.

This was the only outstanding action from our previous inspection. Senior managers could not

confirm a date for completion of the work. In the meantime, the service had implemented

measures to lessen the risks whilst waiting confirmation from the trust.


The service used an electronic system that all staff had access to so they could do their jobs.

Managers and other non-clinical staff used the system to submit and review information needed by

the trust. This included Mental Health Act audits, supervision, appraisal, and mandatory training

data. Managers used this information to monitor performance and ensure the service achieved

compliance levels. We saw evidence that compliance levels were always high across the service.

Ward staff accessed relevant clinical information about patient care. They knew how to access the

system and find the information they needed. Staff kept electronic information confidential such as

ensuring it could not been seen from outside the offices. We found that staff kept up to date

clinical information such as care plans and risk assessments that meant staff had the information

they needed to support patient care.

Managers were able to access service level and clinical information about the service in a timely

and well-organised way. This was an improvement from our previous inspection in 2016 when we

told the trust it must ensure that the service had effective governance systems in place to share

information in a timely manner.

Engagement

Everyone had access to up to date and relevant information about the service. The trust website

included up to date information about Forest Close with links to the most recent Care Quality

Commission inspection findings. The service displayed the most recent report across the site.

Staff provided information booklets about the service to patients and carers. The service involved

patients in their staff recruitment process and carried out a range of methods to gather patient and

carer feedback, which they acted on.


The service was starting to think about making changes to the service following their

transformation almost three years ago. Senior managers told us that staff, patients, and other

stakeholders would be involved in the decision making process.

Staff told us senior managers were accessible and sometimes visited the service. During the

inspection, the senior operational manager visited to attend a meeting with the clinical nurse

manager to discuss aspects of the service.

The service produced a seasonal newsletter that contained information about events and activities

for staff and patients. It also contained personal information such as birthdays and names. The

newsletter was also available in communal areas such as the visiting area in the ‘core house’. This

meant that people could access information that contained personal information about others. It

was not clear that everyone had given permission for information sharing in this way.



The table below shows which services within this core service have been awarded an accreditation, together with the relevant dates of accreditation.

Accreditation scheme Service accredited Comments and date of accreditation / review

AIMS - Rehab (Rehabilitation wards) Forest Close At Peer Inspection stage

The service was working towards achieving accreditation for all three wards in September 2018.

Some staff had completed peer review training and staff felt confident they could achieve the

standards needed.

The service was in the early stages of developing ‘safety huddles’. These short meetings aimed to

focus on improving safety on the wards. Staff could hold these meetings as well as handovers and

team meetings.

The service used the trust quality improvement methodology called microsystems. One manager

had completed additional training and took a lead role in quality improvement. The trust supported

the manager with coaching sessions and away days that shared good practice. The service used

the methodology to improve patient experience based on their feedback about boredom in the

evenings and weekends. Because of the work, the number of activities available had increased

and staff continually monitored progress through patient involvement and feedback. We saw from

activity schedules and patients told us that activities were available seven days a week including

evenings. The manager was positive about the methodology and planned to use the model for

other projects and encouraged more staff to get involved.


Acute wards for adults of working age and psychiatric intensive care units



female, mixed)

The Longley Centre Endcliffe Ward

PICU 10 Mixed

The Longley Centre Maple Ward 17 Mixed

Michael Carlisle Centre Burbage Ward 19 Mixed

Michael Carlisle Centre Stanage Ward 18 Mixed

Sheffield Health and Social Care Trust provides three acute mental health inpatient wards for

adults of working age and one psychiatric intensive care unit. The wards can provide care and

treatment for up to 64 patients. Services are provided at the Michael Carlisle Centre and Longley

Centre as follows:

The Michael Carlisle Centre;

• Burbage Ward – 19 bed mixed sex ward (Includes five detox beds)

• Stanage Ward – 18 bed mixed sex ward

The Longley Centre;

• Maple Ward – 17 bed mixed sex ward

• Endcliffe psychiatric intensive care unit – 10 bed mixed sex ward

The service was able to admit patients who were detained for treatment under the Mental Health

Act (1983), those with deprivation of liberty safeguards in place and informal patients. The majority

of patients were detained under the Mental Health Act at the time of our inspection, there were no

patients with deprivation of liberty safeguards in place.





Ligature risks were identified and managed through regular assessment on each ward. A ligature

point is something that a patient intent on self-harm could use to tie something to in order to

strangle themselves. Individual risks were recorded, risk rated and control measures identified.

The trust had continued to work to reduce the number of potential ligature points via a programme

of works to include door handle replacement and en-suite door replacement. All wards had access

to a number of bedrooms which were reduced ligature specification. Doors in these bedrooms

were alarmed if any weight was applied to the door and had anti-barricade fittings, this meant the

door opened both ways. Bathroom doors in these bedrooms were collapsible.

Staff had mitigated the risks adequately. Mitigation of these risks was managed consistently on

each ward through thorough patient risk assessment, patient observation and regular monitoring

of the ward environment by staff. We observed a constant staff presence in communal areas on all

four wards.

All four wards had a ligature risk assessment completed within the last 12 months and had a copy

of the latest ligature risk assessment available for staff. However, following a serious incident on

Maple ward in September 2017, the trust had taken action to upgrade all en-suite bathroom doors

across all inpatient wards in order to mitigate ligature risks. However, the ligature risk

assessments for all wards had not been reviewed following this serious incident. The trusts’

Ligature Risk Reduction Policy 2017 states ligature risk assessments must be completed more

frequently if a significant event has occurred.

Fire risk assessments were undertaken by the trust’s estates team in collaboration with the ward.

Maple ward reviewed fire risk in December 2017 and had a copy available to staff on the ward.

Three wards had undertaken the annual fire risk assessment in March 2018 and were awaiting

final copies of the report to be produced by the fire officer at the time of this inspection. Ward

managers told us they had received an email to confirm actions that required attention. Issues

identified, included general housekeeping, linen storage and disposal of paper.

We identified blind spots on the two wards (Burbage and Stanage) at the Michael Carlisle Centre, and on Maple ward at the Longley Centre. None of these wards had identified the blind spots on their environmental risk assessments or had put measures in place to mitigate them. On Stanage ward, access to both dormitories was recessed and the clinic room had small corridors on either side. On Burbage ward blind spots were identified by the lounge, room 14 and near the bathroom. At the Longley Centre, blind spots on Maple ward included a corridor to the doctors’ office and an area near the female dormitory. Although staff were present on communal areas at all times, this meant there was an increased risk to staff and patient safety.

Female only lounges were available on all wards.

Staff had access to alarms and nurse call systems were in place for patients on each of the four wards. There was a system in place to test the alarms regularly.

With the exception of patients on Endcliffe, six patients we spoke with, told us they did not feel

safe and seven patients had experienced aggressive behaviour from others.

Over the 12-month period from 1 March 2017 to 28 February 2018 there were no mixed sex accommodation breaches within this core service. The trust had completed work to ensure the acute wards and psychiatric intensive care unit complied with the eliminating mixed sex accommodation guidance. Endcliffe and Maple wards complied with the guidance. Stanage and


Burbage had sleeping accommodation in single rooms within mixed wards with toilet, washing and shower facilities. Each of these wards also had two four bedded bays and these were solely occupied by male or female patients, also with toilet, washing and shower facilities. A local standard operating procedure was also in place to ensure mixed sex wards bedrooms, toilets and bathing facilities were grouped together to achieve as much gender separation as possible. Staff we spoke with acknowledged it was extremely difficult to ensure bedrooms were grouped together for males or females due to the constant demand for beds, flow of patients on the wards and not moving patients that were already settled. However, we identified no concerns and the provider met the requirements as per guidance for mixed sex accommodation.


All four wards were clean, well maintained and furnishings were of a good standard.

Housekeeping staff were visible on all wards and each ward had a senior housekeeper to co-

ordinate and monitor housekeeping activity. All cleaning records were up to date. Stanage had

recently been decorated and Burbage ward looked tired but was scheduled to be redecorated. The

majority of patients we spoke with complimented the wards for their cleanliness.

We observed staff following infection control principles. There were hand gel dispensers across all

wards and we observed staff using these. Hand washing guidance was visible in all kitchen and

bathroom areas. All clinic rooms were fitted with sinks for staff to wash their hands prior to

dispensing medication or undertaking physical health examinations. Personal protective

equipment was available and was stored securely.

The wards participated in the 2017 patient led assessment of the care environment. These

assessments are self-assessments undertaken by teams of trust staff and specially trained

members of the public. They focus on different aspects of the environment in which care was

provided. For the most recent Patient-led assessments of the care environment (PLACE)

assessment (2017) the locations scored better than or equal to similar trusts for all four of the four

aspects overall.


provided


appearance

and

maintenance

Dementia

friendly

Disability

Longley Centre MH - Acute wards for

adults of working age

and psychiatric

intensive care units.

MH - Mental health

crisis services and

health-based places of

safety.

99.6% 96.8% 92.4% 87.7%

Michael Carlisle Centre MH - Acute wards for


and psychiatric

intensive care units.

MH - Other Specialist

Services

MH - Wards for older

people with mental

98.0% 97.3% 88.7% 91.6%


health problems.

Trust overall 99.0% 97.8% 91.1% 91.8%

England average (Mental health

and learning disabilities) 98.0% 95.2% 84.8% 86.3%

Seclusion room


Clinic rooms were well organised, fully stocked and clean. Clinic rooms on all four wards had

examination chairs that reclined and this meant all patients could be physically examined in a

clinical room. A blood pressure monitor, weighing scales, resuscitation equipment and emergency

drugs were available on all wards.

There were four seclusion rooms across the core service. Seclusion rooms allowed for clear

observation using observation windows and closed-circuit television. Two-way communication was

possible through the use of intercoms. All seclusion rooms had toilet facilities and a clock.

At the previous inspection in November 2016, we told the trust they must review seclusion room

provision on each of the wards. There were a number of issues identified with the seclusion rooms

on Stanage, Burbage and Maple wards. During this inspection we confirmed these issues had been

resolved.

A mattress was used rather than a bed in the seclusion rooms on Burbage and Stanage wards due

to the size of the rooms. Maple ward also used a mattress, due to the height of the ceiling, as a bed

created a potential ligature risk.

At the last inspection, the seclusion rooms on Burbage and Stanage wards did not have lock back

doors. Lock back doors are needed so patients can access the bathroom area independently.

Following review by clinical leaders and estates, the trust identified it was not possible to

accommodate lock back doors in the seclusion rooms on Stanage and Burbage wards. During this

inspection staff told us the bathroom doors remained closed and locked when the seclusion rooms

are in use. Unlocked, the door remains a high risk anchor point within the seclusion rooms. Staff told

us each patient would be risk assessed to decide if the door could be unlocked. We saw evidence of

this risk assessment in one of the two seclusion records we case tracked.

The trust’s action plan confirmed that the intercom on Burbage ward was fixed following the review

in December 2016.

The trust successfully addressed the issues on Maple ward regarding privacy and dignity. The

seclusion room was relocated to a different corridor than at the previous inspection. The seclusion

room had an entrance lobby, large seclusion room and accessible en-suite bathroom. Windows

provided clear observation into the en-suite bathroom. The seclusion room had a two way

functioning intercom facility. Large windows with internal, adjustable blinds provided natural light. A

clock was visible for patients to see.

Each ward had a ‘green room’, a protected therapeutic space for patients to access to reduce

distress, agitation or aggression. At the previous inspection in November 2016, we told the trust they

should ensure the operational procedure clearly stated that patients could leave the room at any

point. With the exception of Burbage ward, all wards had updated the standard operating procedure.

Staff on Burbage ward knew that patients could leave the green room.


However, staff did not complete regular checks on all wards of the clinic room temperature, fridge

temperature, defibrillator and emergency equipment in line with trust’s policies. On Stanage and

Burbage wards, there were missed checks of the emergency equipment, the defibrillator and

emergency drugs between March and May 2018. This meant staff on these two wards could not

be assured that equipment was present, working effectively and safe to use. Medicine fridge

temperatures were not regularly checked on Maple, Stanage and Burbage wards. This could

mean that drugs were stored at the wrong temperature and may become less effective.

On Endcliffe Ward, cranberry juice was stored in the medicines’ fridge; this was removed

immediately during the inspection.

All medicines were securely stored on each ward.

Safe staffing

Staffing levels were not always adequate to meet the needs of patients. At the time of inspection,

sickness levels were just above the trust average, vacancies for qualified nurses had increased

16% since the last inspection and fill rates were not always sufficient. Patients did not raise any

concerns about the availability of staff to speak to on the ward; patients could access one to one

time with named nurses, however Section 17 leave did not always go ahead. Seven staff reported

concerns about staffing levels. Staff told us the focus most days was to successfully get through

each shift. Staff also felt the service relied on bank and agency staff to maintain sufficient numbers

on each shift and that the skill mix was not always appropriate to meet the needs of all patients.

The trust had 32 vacancies for qualified nurses and 17 of these vacancies were in this core

service. Stanage ward had the highest number of vacancies for qualified nurses, with eight

vacancies, Burbage and Maple had four vacancies and Endcliffe had one vacancy. Endcliffe ward

was the only ward to have vacancies for nursing assistants, with three vacancies. The remaining

three wards had above the establishment level for nursing assistants. Recruitment was ongoing

and the service was endeavouring to over recruit nurses.

Nursing staff

The table below shows staffing data from 1 February 2017 to 31 January 2018.

Definition






12.8 N/A


7.5% 13%




Total vacancies overall (%) At 31March 2018 11% NA

Total permanent staff sickness overall (%) Most recent month (At 31 January 2018)

7.8% 5%


7.2% 5%





Number of WTE vacancies nursing assistants At 31 March 2018 -1** N/A

Qualified nurse vacancy rate At 31 March 2018 20.5% N/A

Nursing assistant vacancy rate At 31 March 2018 -2.2% N/A

Bank and agency Use



February 2018 2251 (18%) N/A


(Qualified Nurses)

1 March 2017 and 28

February 2018 655 (5%) N/A



1 March 2017 and 28

February 2018 410 (3%) N/A



1 March 2017 and 28

February 2018 6907 (39%) N/A



1 March 2017 and 28

February 2018 3547 (20%) N/A



1 March 2017 and 28

February 2018 791 (4%) N/A


** Negative numbers indicate an over establishment.


There was a spike in nursing staff vacancies in October 2017, the vacancy rate was 29%.


This core service reported an overall vacancy rate of -2% for nursing assistants.

The vacancy rate for nursing assistants was higher than the -23% reported at the last inspection.

This core service reported a vacancy rate for all staff of 12% as of 31 March 2018. This was similar to the rate reported at the last inspection (between 1 August 2016 and 31 July 2017).

The vacancy rate for all staff was at its highest at 15% in October 2017.


Ward/Tea

m

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Endcliffe 1 17 6% 3 16 19% 9 46 20%

Stanage 8 20 40% -1 10 -10% 5 43 12%


Ward

Burbage

Ward 4 20 20% -2 10 -20% 4 43 9%

Maple

Ward 4 26 15% -1 10 -10% 3 49 6%

Core

service

total

17 83 20% -1 46 -2% 21 181 12%

Trust total 32 433 7% 15 353 4% 68 1339 5%


The trust was mitigating the risk of high vacancy rates for qualified nurses by using bank and

agency staff. The trust ensured bank and agency staff received induction and that they were

familiar with the wards, however they were not trained in physical interventions. Ward managers

confirmed they took a proactive approach to identifying and managing shortfalls in staffing,

including redeploying staff across the wards that were trained in physical interventions. This was

supported by block booking bank and agency staff to maintain some continuity in care.

Between 1 March 2018 and 5 June 2018, Burbage ward had 27 night shifts that had less than three RESPECT trained staff and Stanage had five night shifts. Between 1 March 2018 and 5 June 2018 there were four reportable incidents where staff felt this could have compromised a response team for the same period. The trust trained staff in the use of restrictive interventions, using the RESPECT model of management of violence and aggression. The training focuses on the importance of empathy and compassion in understanding why people may display disturbed behaviour. The training emphasises the use of de-escalation techniques before the use of any physical interventions, such as restraint. To safely carry out physical interventions, three trained members of staff are required. The trust confirmed some regular agency staff will be trained in RESPECT.

This meant that some night shifts on these wards did not have the required amount of staff to

safely carry out physical interventions without requiring support from other wards.

There were a number of shifts which could not be filled by bank or agency staff across all four wards. This equated to 7% of shifts across the service. This was highest on Burbage ward, between 1 March 2017 and 28 Feb 2018 352 shifts could not be filled and lowest on Maple ward where 215 shifts could not be filled.


In the same period, agency staff covered 5% of shifts for qualified nurses. Three percent of shifts were unable to be filled by either bank or agency staff.


agency staff


or agency staff

Burbage Ward 2964 641 (22%) 136 (5%) 111 (4%)

Endcliffe Ward

PICU 2893 888 (31%) 330 (11%) 151 (5%)

Maple Ward 3590 478 (13%) 112 (3%) 98 (3%)

Stanage Ward 2800 244 (9%) 77 (3%) 50 (2%)

Core service

total 12247 2251 (18%*) 655 (5%*) 410 (3%)

Trust Total 32,394 4977 7252 900


(15%) (22%) (3%)



In the same time period, agency staff covered 20% of shifts. Four percent of shifts were unable to be filled by either bank or agency staff.


agency staff

Shifts NOT filled by bank or

agency staff

Burbage Ward 3707 1781 (48%) 607 (16%) 241 (7%)

Endcliffe Ward

PICU

6034 2433 (40%) 1341 (22%) 164 (3%)

Maple Ward 3757 768 (20%) 758 (20%) 117 (3%)

Stanage Ward 4215 1925 (46%) 841 (20%) 269 (6%)

Core service

total

17713 6907 (39%) 3547 (20%) 791 (4%)

Trust Total 59,514 21,770

(37%)

5623

(9%)

1760

(3%)


This core service had 12.8 (8%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 14% reported at the last inspection (between 1 August 2016 and 31 July 2017).



Burbage Ward 39.4 4.23 11%

Maple Ward 49.2 5 10%

Endcliffe 39.9 1.8 5%

Stanage Ward 40.9 1.8 4%


Trust Total 1351.6 129.6 8%

The sickness rate for this core service was 9% between 1 February 2017 and 31 January 2018. The most recent month’s data January 2018 showed a sickness rate of 8%. This was similar to the sickness rate of 7% reported at the last inspection in 31 July 2016.


(at latest month)



Burbage Ward 12% 11%


Maple Ward 10% 9%

Stanage Ward 10% 8%

Endcliffe 6% 6%


Trust Total 8% 7%

The below table covers staff fill rates for registered nurses and care staff between November 2017 and February 2018.

All wards had a fill rate of over 125% for care staff for all day shifts.

Burbage ward had a fill rate below 90% for registered nurses for all day shifts.

Maple ward had a fill rate below 90% for nursing staff for night shifts for all months reported. Key:

> 125% < 90%

N – Nurses

C – Care staff


N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

November 2017 December 2017 January 2018 February 2018 Burbage 87.2 216.0 113.6 332 86.9 214.4 88.4 380.6 84.6 200.3 93.4 322.6 80.3 184.8 101.7 320.9

Maple 73.9 160.1 79.3 320 89.4 214.7 78.5 528.5 97.1 246.2 80.8 627.3 85.3 267.5 70.2 592.9

Stanage 71 223.6 95.1 283.2 78.2 277.7 68.1 434 75.5 273.4 103.2 365.7 71.3 282.8 91.3 396.7

Endcliffe 79.7 176.5 88.3 217.3 83.3 195 100.5 250 93.4 239.5 100.0 308.6 101.8 254.4 100.1 335.3

Ward managers consistently told us they were able to adjust staffing levels to meet the changing

need of the patient group. Staff told us there was always at least one qualified nurse on each shift

at all times.

During this inspection we requested more up to date information regarding fill rates for qualified staff to establish if there had been any improvement in staffing. Themes remained consistent, Maple ward continued to have below 90% fill rates for qualified nurses on night shifts, in March and April they achieved less than 80%. Stanage continued to have less than 80% fill rate for qualified staff on day shifts, although this improved slightly in May 2018. Burbage and Stanage wards continued to achieve above 95% fill rate for qualified staff on nights. Endcliffe ward maintained fill rates above 100% for qualified staff on all shifts.

The service consistently maintained fill rates for nursing assistants above 100% for all shifts. Fill

rates for nursing assistants ranged from 160% to 627%.

The impact of not adequately maintaining safer staffing levels alongside a reliance on bank and

agency staff was evident during this inspection. Staff were busy and consistently in demand.

Medical staff

Consultants and junior doctors provided medical cover across all wards. There was access to a

doctor 24 hours per day who could attend the ward quickly in an emergency. All wards had a


dedicated consultant psychiatrist. Medical cover out of hours was provided by a city wide on call

duty system, approximately 10 miles from the Michael Carlisle Centre and five miles from the

Longley Centre. Staff had access to basic life support equipment in the event of a medical

emergency.

Between 1 March 2017 and 28 February 2018, 48 shifts were filled by bank staff to cover


In the same time period, agency staff covered 257 shifts. Zero shifts were unable to be filled by

either bank or agency staff.

Staff and patients on all wards could access a doctor when needed.

Ward/Team Shifts filled by bank staff Shifts filled by agency staff Shifts NOT filled by bank or agency staff

Burbage Ward 48 256 0

Mandatory training

The majority of staff had completed required mandatory training. The trust compliance target for mandatory training was 80%. The compliance for mandatory and statutory training courses at 28 February 2018 was 86%. Of the training courses listed five failed to achieve the trust target and of those, three failed to score above 75%. Mandatory training course that did not achieve the trust target were:

• Autism Awareness (77%)

• Mental Health Act (75%)

• Deprivation of Liberty Safeguards Level 1 (73%)

• Information Governance (72%)

• Dementia Awareness (71%)

The training compliance reported for this core service during this inspection was higher than the 51% reported at the last inspection. Ward managers told us a co-ordinated approach to booking training for staff was now embedded on the wards and staff had dedicated time to complete the required mandatory training. The mandatory training steering group monitored compliance and reported regularly to the executive directors group.

Key:




Trust target % Trust wide mandatory/ statutory training total %




Falls) 96% 80% 97%











Deprivation of Liberty Safeguards

Level 2 88% 80% 85%










Level 1 73% 80% 80%







During this inspection we reviewed 17 care records. The service used a standardised risk

assessment tool to support clinical risk management and this was based on Best Practice

Guidance (Department of Health, 2007). The risk assessment tool was called the Detailed Risk

Assessment and Management Plan.

All 17 risk assessments were up to date and had been regularly reviewed. Staff recorded the risk

history of all patients in detail and current risks were clearly documented. We saw evidence that

risk assessments were updated following incidents. The risk assessment addressed patient views

regarding mixed sex accommodation and identified the need to adjust observation levels to reflect

vulnerability.


Staff identified and responded to the changing needs of patients. The trust had an observation

policy to support and protect patients and staff. We saw staff regularly and consistently completing

general observations of patients on the wards, as required by trust policy. The previous inspection

highlighted a pilot project undertaken on Stanage ward which saw the use of an electronic tablet to

support staff undertaking routine observations. During this inspection we observed that this

practice had now been rolled out across all wards. The tablet alerted staff regarding which patients

were on specific observations and the frequency of observation required. The use of technology

ensured the service was responsive to individual patient risk and need. All ward managers told us

staffing had been increased to fulfil the increased levels of observations.


There were minimal blanket restrictions within this core service. Individual access to bedrooms

varied across the wards. Not all patients had keys to their bedrooms, as many keys had been lost

and not replaced. Patients on Endcliffe ward required staff to open their bedroom doors as there

was a design fault with the doors; the ward manager confirmed these were awaiting repair.

Accessible bathrooms were locked on all wards due to the increased ligature risk and patients

required staff to open these. Based on individual risk assessment, patients could use these

unsupervised. Patient access to the laundry was supervised.

All patients had access to personal mobile phones, based on an individual risk assessment. All

patients had access to outside space. Patients could access hot and cold drinks during the day

and night. Staff implemented the trusts’ search policy in the least restrictive way. Staff told us

patients were not routinely searched and this reflected the trusts search policy and least restrictive

practice approach to care.

During this inspection the trust delivered training to staff on least restrictive practice. We saw

evidence that a standardised approach across the wards was being rolled out. Information for

patients and families was meaningful and set out clear expectations.

The implementation of the trusts’ smoke free policy was poor. The trust committed to a smoke free

environment in 2016. Patients, staff and visitors were not permitted to smoke on site. We observed

that smoking cessation advice and treatment was available on all wards. Staff we spoke with

stated smoking by patients remained a significant issue. During this inspection we consistently

saw evidence that smoking had occurred in outdoor spaces on Burbage, Stanage and Maple

wards. We saw patients smoking frequently and staff did not challenge any patients.


Staff were trained in the use of restrictive interventions. Staff used restraint and seclusion only after de-escalation attempts had failed and reported restraint and seclusion episodes using the electronic incident reporting system.

Staff we spoke with understood the definition of seclusion and that restraint should be used only

after other de-escalation attempts had been made. Staff were able to describe methods they

would use to manage incidents prior to attempting restraint. Staff told us they would only use

restraint if it was necessary for the safety of patients and staff. The acuity of patients across the

service was high, however, in comparison the number of seclusions was low.

This core service had 283 incidents of restraint (on 161 different service users) and 259 incidents

of seclusion between 1 March 2017 and 28 February 2018. Over the 12 months, there was an

increase in the incidence of restraint in December 2017 (59 incidents of the use of restraint).

Maple ward had the highest number of restraints, however the data included those patients who

used the health based place of safety (136 Suite). Endcliffe ward had the highest use of seclusion.

Governance officers and the risk department monitored the use of restrictive interventions. A

weekly restrictive practice report was produced, which provided information on post incident

reviews, seclusion, restraint and rapid tranquilisation. This information was shared with ward

managers, senior managers, chief nurse and the trust leads for RESPECT and patient safety.


2018.



restrained


prone restraint

Rapid

tranquilisations

Maple ward

(incl 136) 60 89 60 0 (0%) 16 (18%)

Endcliffe

ward 94 77 43 1 (1%) 13 (17%)

Stanage

ward 66 72 30 0 (0%) 21 (29%)

Burbage

ward 39 45 28 0 (0%) 28 (62%)

Core service

total 259 283 161 1 (<1%) 78 (28%)

There was one incident of prone restraint which accounted for <1% of the restraint incidents.

Over the 12 months, there was a peak in the use of restraint in December 2017, where there were a total of 59 incidents.

Incidents resulting in rapid tranquilisation for this core services seem to have been fluctuating, with the highest numbers in April 2017.

There have been no instances of mechanical restraint over the reporting period.

Over the 12 months, there was a decrease in the use of seclusion. There were 30 incidences in March 2017 which reduced to 15 incidences in February 2018.

22

39

108

14

4

149

19

59

46

39

0 0 1 0 0 0 0 0 0 0 0 00

10

20

30

40

50

60

70

Mar 17 Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18

Total restraints over the 12 month period

Number of incidents of the use of restraintsNumber of prone restraintsNumber of mechnical restraintsNumber of incidents resulting in the use of rapid tranquilisation


Staff were not always adhering to the trust policy in carrying out and contemporaneously recording

nursing and medical reviews as required by the trust and Mental Health Act Code of Practice.

We reviewed six seclusion records. Seclusion care plans were in place for all patients, detailing a

clear rational for seclusion. However, only two of the records had a clear seclusion exit plan in

place. This meant the patient was not aware of what was required of them, in order to allow the

seclusion to end. This also meant that patients may have remained in seclusion for longer periods

than were necessary. None of the six records reviewed demonstrated that the post seclusion

review had been completed by staff, as required by the trust. Monthly clinical governance

meetings maintained oversight of these and monitored completions, refusals and incomplete

reviews but had not identified these issues

The trust policy on seclusion also states that ‘nursing observations must be recorded every five

minutes for the first hour and then at intervals of no more than ten minutes thereafter’ and ‘nursing

reviews should take place at least every two hours. These should be undertaken by two

individuals who are registered nurses’. Of the six records we reviewed, we found that there were

gaps in the recording of nursing and medical reviews for three records. This meant staff were not

carrying out the necessary reviews as outlined in the trust policy and the Mental Health Act Code

of Practice. The recording of information in these three records was fragmented as information

was recorded in paper records and on the electronic patient record.

Staff did not always adhere to trust policy in carrying physical health observations following rapid tranquilisation. Rapid tranquilisation is medication which is given in the short-term management of disturbed or violent behaviour. The trust policy stated after intramuscular administration, ‘physical health observations should be monitored and recorded every hour until there are no concerns about their physical health status.’ We reviewed seven rapid tranquilisation records and found five records did not have the required observations carried out. Therefore, staff did not always follow the trust procedures. Data provided by the trust prior to this inspection indicated the highest use of rapid tranquilisation was on Burbage ward. We discussed this with the ward manager and local data did not reflect this. We discussed our concern further with the clinical governance team and they confirmed an issue with the accurate recording of rapid tranquilisation within the electronic incident form had been identified in April 2018. We reviewed the reducing restrictive interventions reports from March 2018 to May 2018 and these reports confirmed a discrepancy in the reported figures. The reports highlighted a more even spread across the wards in the use of rapid tranquilisation. The clinical governance team confirmed the reporting issue had been discussed with senior managers and contingencies were in place. Governance officers manually reviewed all incident reports to identify

30

35

14 13

21 2219 18

23

31

1815

0

5

10

15

20

25

30

35

40


Total seclusions over the 12 month period

Number of incidents of the use of seclusion


if rapid tranquilisation had been used, to ensure oversight of rapid tranquilisation could be maintained. There were no instances of long term segregation over the 12-month reporting period.

Safeguarding



The trust required all staff to complete safeguarding training for adults and children and the level of

training required was determined on an individual role basis. Compliance for level two training in

child safeguarding was 92% and for adults 87%. Level three training in child safeguarding was

84%. During this inspection we observed that safeguarding information was easily accessible to

staff on the intranet and displayed on each ward.

All staff members we spoke with were able to identify potential safeguarding concerns relevant to

the patient group. Staff spoke confidently about how they would respond to such a concern and

would seek advice from the trust safeguarding leads. We spoke with a safeguarding lead for the

trust and confirmed staff regularly contacted them for advice and support. Several members of

staff described examples of safeguarding referrals made to the safeguarding team, these included

concerns about different types of abuse. The single point of access and care co-ordinators

investigated safeguarding concerns and worked with other agencies, such as the police and local

authority.

When children visited the service, there were processes in place to keep them safe, however these were not sufficiently robust. Maple and Endcliffe wards had visiting rooms away from the main patient areas. Burbage and Stanage wards had rooms available on the ward and could access additional rooms in the occupational therapy department.

During this inspection one incident gave us cause for concern, a child visitor was left unsupervised

by family members in the green room on Burbage ward and staff were not clear for how long. The

green room operational procedure clearly indicates the room should not be used for visits and the

ward did not have a local process for child visits, as indicated in the trust policy. The incident had

been recorded but no safeguarding alert had been made. We discussed our concerns with the

ward manager and they informed us they were aware of the incident, however no investigation

had commenced or action taken to ensure this type of incident could not be repeated. Following

our inspection, the trust confirmed a safeguarding alert had been made in relation to this incident.

This core service made no safeguarding referrals between 1 February 2017 and 31 January 2018. We clarified this information with the trust and they confirmed 67 adult safeguarding referrals were made from this core service.

Sheffield Health and Social Care NHS Foundation Trust has submitted details of zero serious case reviews commenced or published in the last 12 months [1 March 2017 and 28 February 2018] that relate to this core service.



The service had a secure electronic system to store and record patient information. Access to the

system was password protected. Some patient information remained paper-based, such as

seclusion records. Staff told us these documents were scanned into patient records. Ward

managers told us that agency staff did not have access to the electronic care record. Agency staff

received information regarding risk and care plans during clinical handovers. Agency staff were

expected to handover patient information to regular staff members to record in the patient care

record. However, agency staff could add some notes to care records via the electronic tablet when

completing observational checks of patients.


We looked at 40 electronic prescription charts and the clinic environment across all four wards.

We saw evidence of a monitoring system in place for the use of high dose antipsychotic

medication and this included additional physical health checks and blood tests.

We spoke with pharmacy staff and confirmed they attended the wards regularly to support

medicines reconciliation, provide clinical support, review prescription charts and completed

medicines related audits. Pharmacists were part of the ward multidisciplinary team and were

available to speak with patients on request.

However, the management of medicines was not always sufficient within this core service. We

reviewed the controlled drug registers on all four wards. Whilst, staff told us that these drugs were

regularly checked, only Maple ward had successfully completed all the required weekly checks.

The remaining three wards had gaps in their audits.

The recording of controlled drugs was not compliant with trust policy and we found discrepancies

in the recording of controlled drugs on Stanage and Maple wards. We raised our initial concern

with a pharmacist during this inspection and the trust provided a written response detailing how

they were going to address these issues with staff. Staff on Burbage and Endcliffe wards did not

regularly check stock levels of controlled drugs, as required by the trust.

We also found that patient specific medicines such as eye drops and insulin were not labelled

correctly. On Stanage ward, eye drops did not indicate when they were opened. On Burbage

ward, two insulin pens had only the patient initials on the pens. On Maple ward, eye drops were

patient specific but had passed the use by date. On Endcliffe ward, medicine bottles were not

dated when opened.



Between 1 March 2017 and 28 February 2018 there were three STEIS incidents reported by this core service. Of the total number of incidents reported, the most common type of incident was Apparent/actual/suspected self-inflicted harm with two.



We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with STEIS.

The number of serious incidents reported during this inspection was higher than the two reported at the last inspection.

During this inspection we reviewed the data provided by the trust in relation to the three serious

incidents reported for this core service. One serious incident indirectly related to this core service,

therefore we did not focus on this. We examined closely the two remaining incidents in relation to

the action the trust took and how learning was identified and shared within the service.

Following the death of a patient, the trust investigated the incident and identified areas of

improvement the service must make. The trust took immediate action and replaced all bathroom

doors within patient bedrooms. We reviewed the action plan and the majority of the required

actions were incomplete, although most were in progress and within agreed timescales. The ward

manager also provided an update on each specific action. We reviewed clinical governance

meeting minutes and team business meeting minutes from all wards following the release of the

report in March 2018 and there was no evidence to support that required actions or learning had

been shared across the service.

Following an incident at height in 2017 and a similar incident in early 2018, the trust completed

work to remove door handles and assess the requirement for anti-climb guttering on one ward.

Again, there is no evidence to support that the nature of these issues were considered relevant to

other wards.

Number of incidents reported

Type of incident reported on STEIS Stanage

ward

Maple

Ward

Burbage

ward

Endcliffe

ward

Total

Apparent/actual/suspected self-inflicted

harm meeting SI criteria

1 1 0 0 2

Pending review (a category must be

selected before incident is closed)

1 0 0 0 1

Total 2 1 0 0 3


All staff regularly reported incidents, however, learning from incidents was limited. The trust had

an electronic system for reporting incidents. Staff had a clear understanding of what constituted an

incident and how to report it. Agency staff did not have access to the incident reporting system and

had to report incidents to regular ward staff. The majority of staff told us they received a de-brief

and support following serious incidents and additional support was available through weekly staff

support meetings on each ward. Patients received a de-brief following incidents, although this did

not happen following every episode of seclusion.

We reviewed clinical governance meeting minutes from March 2018 to May 2018 from all four

wards. The quality and consistency of these minutes varied across the service. All wards followed

a standardised template that reflected the five domains of the Care Quality Commission. Burbage

and Stanage used data effectively to scrutinise incidents and to identify themes and trends specific


to their ward. The meeting minutes for Endcliffe and Maple did not contain detailed information.

Outcomes and actions from these meetings were limited.

Some staff we spoke with told us feedback and learning was received in handover, team business

meetings or via email. We observed that the safety huddle on Maple was a very responsive

mechanism for providing timely feedback to staff and raising awareness of incidents. Learning

from trust wide incidents was available through the intranet. Most managers we spoke with

confirmed that learning from incidents within the service was an identified area of improvement

and that there was a need to ‘close the loop’ regarding learning.

The duty of candour is the requirement that staff are open and honest to patients and/or carers

when things go wrong with care and treatment. Staff knew about their responsibilities under duty

of candour and some staff gave examples from their practice where the principles had been

applied.




Is the service effective? Assessment of needs and planning of care

We reviewed 17 electronic patient care records. Staff completed a comprehensive mental health

assessment for all patients upon admission, taking into consideration the patients physical,

psychological and social needs and this was evident in all 17 records reviewed. All patients

received an assessment of their physical health needs in a timely manner after admission. We

noted three patients had declined to have their physical health assessed and staff had repeatedly

followed these patients up and offered further opportunity to have this assessment.

Of the 17 care records reviewed, 14 care plans reflected all issues identified in the initial risk

assessment. Whilst we saw the use of an interpreter in a patients’ care and staff described how

this supported communication, this was not reflected in the care plan. Staff regularly reviewed and

updated care plans

The majority of care plans were holistic, personalised and goal and recovery-orientated. Fifteen

care records contained care plans that were personalised and had evidence of co-production

between staff and patients, with one care record being particularly good in relation to care plans

addressing complex physical health needs and life-threatening reactions to medication. The

majority of care plans reflected the patient voice.

All four wards completed quarterly care plan audits. This information was used in the clinical

governance meetings to identify areas of improvement. Data analysis identified themes and trends

from each ward. The service agreed to benchmark against Maple ward, as all care plans sampled

were collaborative.


The service provided a range of care and treatment interventions suitable for the patient group.

Psychiatrists told us that when prescribing medication, National Institute for Clinical and

Healthcare Excellence guidance was followed, along with recommendations from the Royal

College of Psychiatrists.

We examined 40 electronic prescription charts and all prescribed medication was within British

National Formulary limits. An effective monitoring system was in place for those patients

prescribed high dose antipsychotic medication.

The service had a commitment to improving access to physical healthcare for patients. The

majority of patients had a comprehensive physical health examination and assessment upon

admission to each ward. We saw evidence in care records that long-term health conditions such

as asthma, diabetes and epilepsy were addressed. Staff had referred patients to specialist

services, including diabetes team, ophthalmology and neurology. At the point of admission most

patients received screening for the risk of malnutrition and staff used a recognised screening tool.

Clinical governance meeting minutes confirmed Burbage and Stanage ward had a compliance rate

for this tool between 58-60% for 12 months up to March 2018. No data was available in the clinical

governance meeting minutes for Maple and Endcliffe. Staff could access the electronic patient

care record to obtain the outcome of blood test results for patients. This proactive approach

ensured patients physical health needs were being met.


Staff supported patients to live healthier lives. Information was available to patients on a variety of

issues, including healthy eating, exercise, substance misuse and smoking cessation. Staff were

committed to increasing levels of physical activity, we observed patients attending the gym and

participating in outdoor activities such as cycling, walking and basketball. Occupational therapy

teams provided an activity programme that covered seven days a week and evenings.

We spoke with clinical staff and found that knowledge of best practice was fair. Some staff

struggled to describe how guidance from the National Institute for Health and Care Excellence

was implemented on the wards. Senior clinicians and medical staff demonstrated good

understanding of national guidance in relation to prescribing, depression and the management of

violence and aggression.

Interventions and treatments recognised by the National Institute for Health and Care Excellence

were promoted alongside medication regimes. The service used a range of outcome measures

and rating scales, nursing staff and the occupational therapists completed these. The occupational

therapist used The Model of Human Occupation tool to assess patient functioning in cognitive and

motor skills. Nursing staff used the mental health clustering tool to evaluate the patients’ mental

health, presentation and diagnosis to identify a package of care.

All wards had access to psychological services. However, staff told us availability was reduced

due to vacancies. Recruitment was ongoing at the time of this inspection. Psychology

predominantly supported staff through regular formulation meetings, an approach to encourage

teams to formulate a joint understanding of the difficulties patients may experience and support

the care and treatment of those patients. Referrals for psychological input were made through the

multi-disciplinary team. Psychology staff provided some 1:1 interventions for patients based on a

cognitive behavioural therapy framework.

This core service participated in the following clinical audits as part of their clinical audit

programme in the 12 months leading up to the submission of the provider information return.


completed


audit

Audit of NICE

Guidelines for

Borderline

Personality

Disorder

Burbage, Maple

and Stanage

wards

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive

care units

Clinical Feb-18

To discuss with relevant

quality and service

management teams

Audit of Physical

Investigations for

Admitted

Psychiatric

Patients

Burbage ward

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive

care units

Clinical Apr-17

The audit findings were

presented at the trust

weekly training event –

Quality Improvement

Group: Physical Health

Screening.

Increasing awareness of

the Physical Health

Investigations SOP.

Omitted and

Delayed Stanage ward

MH - Acute

wards for

adults of

Clinical on-going Already agreed to extend

scope of audit.


Medicines working age

and

psychiatric

intensive

care units

Physical Health

Monitoring

Before, During

and After Rapid

Tranquilisation /

Emergency

Sedation

Endcliffe ward

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive

care units

Clinical on-going Awaiting findings

ECG Monitoring

on Admission

Stanage,

Endcliffe,

Burbage and

Maple wards

MH - Acute

wards for

adults of

working age

and

psychiatric

intensive

care units

Clinical on-going Awaiting findings

Collaboration

with Primary

Care Clinicians

Service users

on CPA

Provider

wide

Clinical on-going Changes made following







solution.

Record keeping

audit 2016/2017

Trust wide Provider

wide

Clinical on-going From data collected so far:


staff on use of



relevant policy.

Audit of risk

assessments

2016/2017

Trust wide Provider

wide

Clinical audit March 2017 Local action plans to





in 2017/18.

Audit of risk

assessments

2017/2018

Trust wide Provider

wide

Clinical audit ongoing Await findings

Audits of care

plans

Trust wide Provider

wide

Clinical audit January

2018


small scale audits.


teams.

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG43

Transition from

children’s to

Trust wide Provider

wide

Clinical audit June 2017 Findings fed into






transitions


adults’ services

for young

people using

health or social

care services

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG13

Workplace

health:

management

practices

Trust wide Provider

wide

Clinical audit September

2017



future

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG58

Coexisting

severe mental

illness and

substance

misuse:

community

health and

social care

services

Trust wide Provider

wide

Clinical audit December

2017

Action plan under

development

Medical staff attended weekly meetings which were used for training and to examine current best practice and guidance. Medical staff discussed the outcome from completed audits. Ward managers completed quarterly care plan and risk assessment audits, outcomes were

monitored through monthly clinical governance meetings and quarterly performance review

meetings with senior operational managers in the crisis and emergency care network. Clinical

administrators had a key role in supporting ward managers with audit activity. On a weekly basis

staff completed updates on activities that required completion following a patient’s admission.

Maple ward had developed a task sheet to identify all areas of care to be addressed, including

areas that were incomplete. The use of colour acted as a visual quick glance guide to identify what

actions had been completed and those that required attention.


The service had access to a comprehensive multidisciplinary team. This included consultant

psychiatrists, junior doctors, pharmacists, occupational therapy staff, nurses, support workers,

psychology, physiotherapist, activity workers and administrators. Staff could also access additional

specialist knowledge and support through the trusts safeguarding and Mental Health Act teams.

All staff had undertaken an induction programme. The trust undertook employment checks to

ensure staff were suitably qualified. Staff told us they had had opportunities to develop additional

skills and knowledge in relation to psychosocial interventions. Endcliffe ward had involvement with

the national association of psychiatric intensive care units, an organisation committed to


developing and promoting the speciality of such units. Endcliffe hosted an event in 2017 and

attend quarterly meetings. Staff from Endcliffe accessed weekly teaching and learning club

sessions. The purpose of this initiative was to support staff in learning on the ward, themes

discussed included the Mental Health Act, physical health, substance misuse and medical

diagnosis. Training was provided by a range of professionals from the trust. All qualified nurses

completed ‘Medicines With Respect’ training to demonstrate competence in administering

medications.

Some staff had undertaken additional training in food hygiene and physical exercise. This

extended the scope of their roles and supported therapeutic activities on the wards.

Psychology staff provided direct support to staff following serious incidents.

The trust’s target rate for appraisal compliance is 90%. As at February 2018, the overall appraisal

rates for non-medical staff within this core service was 97%.

The rate of appraisal compliance for non-medical staff reported during this inspection was higher

than the 88% reported at the last inspection.

Ward name

Total number of



Total number of



appraisal

% appraisals

Burbage Ward 42 40 95%

Endcliffe 40 40 100%

Maple Ward 54 50 93%

Stanage Ward 45 45 100%


Trust wide 1495 1440 96%


rates for medical staff within this core service was 100%.

The rate of appraisal compliance for medical staff reported during this inspection was higher than

the 98% reported at the last inspection.

Ward name

Total number of



Total number of

permanent medical


appraisal

% appraisals


Endcliffe 1 1 100%

Maple Ward 1 1 100%





The service was not meeting the trust target for compliance with clinical supervision. Not all staff received clinical supervision regularly. The trust was aware they were not accurately documenting and reflecting all elements of supervision activity. The trust policy stated that staff ‘should generally complete a minimum of 1 to 1½ hrs every 4-6 weeks.’ The trust’s target for clinical supervision was 66%. Between 1 March 2017 and 28 February 2018

the rate across all four teams in this core service was 36%. The rate of clinical supervision

reported during this inspection was lower than the 60% reported at the last inspection.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. Ward name Clinical supervision

sessions required


sessions delivered


rate (%)



Endcliffe 146 43 29%

Maple Ward 197 46 23%



Staff did not raise concerns about not being able to access supervision. We spoke with ward managers and assistant ward managers regarding supervision. Supervision was available to staff, however, the acuity of patients on all wards and competing clinical priorities, often meant individual clinical supervision did not go ahead as planned. All staff had access to weekly staff support meetings on each ward, which provided an opportunity for staff to have protected time to discuss issues relevant to staff. Ward managers told us attendance was good and staff told us they valued the time. Staff also attended formulation meetings with psychology based on each ward and had access to regular team business meetings.

Ward managers recognised the recording of clinical supervision was not accurate. The trust introduced an electronic form to record supervision. However this was not consistently completed across the service. Compliance with supervision was regularly reviewed and monitored through clinical governance meetings on each ward and the requirement to improve this activity was recorded, however no plans were identified in how to achieve this.

Between 1 March 2017 and 28 February 2018 the clinical supervision rate for medical staff was 400%. The trust’s target for clinical supervision is 66%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was higher than the 60% reported at

the last inspection.


sessions required


sessions delivered


rate (%)





Multi-disciplinary and inter-agency team work

The service had regular and effective multidisciplinary meetings. There were three daily clinical

handovers within the team; these occurred when the shift changed. In addition, Maple ward

participated in a daily safety huddle, involving all staff members on the ward at the time.

Embedding this process remained a challenge due to acuity on the wards.

The service held daily and weekly multi-disciplinary meetings. Daily multi-disciplinary planning

meetings were held to discuss each individual patient. Staff told us these were effective for

discussing information regarding patients’ needs, risk and levels of observation. It also enabled

more effective and responsive planning for patients. Occupational therapy staff told us they found

this helpful and it reflected a team approach to care. Each ward also had weekly multi-disciplinary

meetings to review patients’ care and treatment. With the exception of Endcliffe ward, all wards

had a dedicated discharge co-ordinator. This role ensured an inclusive approach to patient

discharge, involving community mental health teams, housing and benefits. The wards had

established effective working relationships with mutual aid organisations, social and community

networks.

Staff told us that independent mental health advocates, pharmacists and carers attended multi-

disciplinary meetings. We observed one multi-disciplinary meeting during this inspection. The

meeting took a multidisciplinary approach to care and treatment. Although the patient had declined

to attend, their views were represented throughout. The discussion remained patient focussed and

discharge planning was thorough. A need to provide an independent mental capacity advocate

was identified in relation to ongoing care and treatment. Staff updated care records during the

meeting and verbal feedback was provided to the patient.


Practice

As of 28 February 2018, 75% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years. The training compliance reported during this inspection was higher than the 33% reported at the last inspection.

Staff we spoke with had a fair understanding of the Mental Health Act and the Code of Practice

guiding principles. Staff told us they would access support from the wider clinical team and the

Mental Health Act office, as they were confident in the depth of knowledge and understanding

available.

The trust employed Mental Health Act officers who provided guidance on the application of the

Mental Health Act and its Code of Practice to staff. The Mental Health Act office was responsible

for ensuring that all Mental Health Act documentation was accurate and complete. Ward staff had

access to a checklist to support them in the scrutiny of Mental Health Act documentation. Each


ward had an identified contact within the Mental Health Act office and all staff knew who they were

and were confident in contacting them for advice. Staff told us they could access the policy and

procedure via the intranet.

The service had an organised system for storing detention paperwork, consent to treatment forms,

approved mental health professional reports and second opinion approved doctor reports. This

systematic approach ensured the Mental Health Act officers had oversight for patients’ ongoing

detention. The trust made provision for safe storage of detention paperwork. Copies of Mental

Health Act documentation were scanned onto the electronic patient care record which meant all

staff could access them when needed.

All wards had access to an independent mental health advocate and staff told us they visited

regularly. We observed information about this service on notice boards on all wards and via the

electronic patient information store on Stanage ward.

We reviewed care records of 15 detained patients. Of these, 13 care records showed evidence

that patients had their rights under the Mental Health Act explained to them at regular intervals.

Two records contained reminder letters to prompt staff to complete this. The majority of patients

we spoke with confirmed this. Both staff and patients told us that escorted leave from the ward

was occasionally cancelled due to staffing levels. All wards consistently took a flexible approach to

facilitating escorted leave throughout the day. We asked the trust to provide us with information on

the frequency of cancelled Section 17 leave and the trust confirmed they were not able to report

on the frequency of this.

Staff discussed Section 117 aftercare with most patients, of the 15 care records reviewed, ten care

plans referenced some discussion.

Ward managers completed weekly Mental Health Act documentation audits and these were

monitored by the Mental Health Act office. During a recent Mental Health Act monitoring visit by

the Care Quality Commission, the unlawful detention of a patient was highlighted by the trust.

During this inspection we discussed the learning from this incident with the Mental Health Act

Manager. They confirmed there had been a change in process to safeguard against a

reoccurrence of such an incident. The trust also met with the family to offer an apology and an

explanation.

The CQC completed four Mental Health Act monitoring visits to this core service between

February 2017 and May 2018. Issues identified included eliminating mixed sex accommodation,

timely seclusion reviews and availability of information. The trust had submitted provider action

statements to identify how they intended to address these issues.

Informal patients were aware of their rights and there were signs on display informing them they

could leave. Informal patients we spoke with confirmed staff had discussed with them on

admission their rights.






renewed every three years. The training compliance reported during this inspection was higher

than the 17.5% reported at the last inspection.

The trust had a policy to guide staff and this was available on the intranet for staff to access. The

Mental Health Act office provided information and support to staff in relation to the Mental Capacity

Act. Staff audited the application of the Mental Capacity Act as part of the Mental Health Act audit.

The outcomes of these audits were monitored through regular clinical governance meetings and at

quarterly performance review meetings with senior clinical operational managers within the crisis

and emergency care network.

Capacity to consent to treatment was assessed on admission and with exception of one, all care

records demonstrated this had been completed.

Staff we spoke with had a fair understanding of Mental Capacity Act and its five statutory

principles. Care records demonstrated that staff had completed capacity assessments when

required, which were time and decision specific. Examples included, suitability for long term

supported accommodation and refusal of essential physical health medication. Staff did not make

decisions in isolation relating to capacity, and discussion and decisions were documented in

medical and multidisciplinary reviews. Staff recorded the outcome of assessment clearly in the

patients care record.

The trust told us that three Deprivation of Liberty Safeguard (DoLS) applications were made to the Local Authority for this core service between 1 March 2017 and 28 February 2018. CQC received zero direct notifications from Trust between 1 March 2017 and 28 February 2018. The number of DoLS applications made during this inspection was higher than the zero reported at the last inspection. We discussed this with the trust and they confirmed these three applications did not relate to this core service.

At the time of our inspection, the majority of patients admitted to the service were detained under

the Mental Health Act and some patients were voluntarily in hospital. The trust had a policy to

guide and assist staff to apply the Deprivation of Liberty Safeguards.




We spoke with 18 patients during this inspection, received comment cards from eight additional

patients, and met with 11 patients at two focus groups. We spoke with eight carers. Feedback was

mostly positive across all four wards. Patients told us staff were professional, caring and

reassuring. Patients felt respected by staff and commented how staff were always there to provide

help and support. We saw how one patient had been supported by the ward in their cultural and

religious needs during Ramadan. The patient could access food when required and medication

was provided at alternative times.

Throughout our inspection, we observed a mix of positive interactions between staff and patients.

Whilst we saw times when staff were very busy and were not always able to meet the needs of

patients in a timely manner, we also observed interactions where staff displayed compassion,

understanding and mutual respect, with staff directly supporting patients in a calm, caring and

reassuring manner. Staff demonstrated respect for patients by discreetly carrying out

observational checks. During the inspection, we observed incidents of patients becoming

distressed and agitated. Staff managed these situations well by acting quickly and responding

appropriately to patients’ needs. Business meeting minutes for all wards demonstrated that staff

discussed the privacy and dignity of patients during the use of restrictive interventions, such as

restraint. The majority of patients we spoke with felt staff had a genuine interest in their wellbeing.

Staff supported patients to understand their care, treatment and conditions. We saw evidence in

care records of detailed care plans and discussions regarding chronic physical health problems.

Doctors discussed with patients the importance of physical health assessments in relation to their

care.

Staff maintained the confidentiality of patient information through the use of secure access to

electronic patient records. Patient information was not on display in offices.

The 2017 Patient-led assessments of the care environment (PLACE) score for privacy, dignity and wellbeing at two core service locations scored better than similar organisations.

Site name Core service(s) provided Privacy, dignity and

wellbeing

Longley Centre

MH - Acute wards for adults of working age and

psychiatric intensive care units.

MH - Mental health crisis services and health-based

places of safety.

94.7%

Michael Carlisle Centre



MH - Other Specialist Services


problems.

94.3%

Trust overall 96.6%


England average (mental health and

learning disabilities) 90.6%

Involvement in care


Staff we spoke with told us that new patients were orientated to the ward by a member of staff.

With the exception of one patient, all patients we spoke with confirmed they had been shown

around the key areas, such as toilets, showers, bedrooms and dining room.

We reviewed 17 care records. In the majority of the care records we reviewed, there was evidence

that care plans were co-produced with patients. Four records did not demonstrate any evidence of

patient involvement. The trust used a colour coding system to indicate the level of involvement the

patient had in their care plan. The five different colours indicated involvement from ‘I do not want

to be involved in this goal at the moment’ to ‘I feel I am taking the lead on my goal’. Five patients

told us they were not involved in planning their care and did not have a copy of their care plan. Of

the 17 care records reviewed, 12 patients had a copy of their care plan, one did not and four

records were unclear. Each patient had a collaborative care plan, this was a universal template

used in both community and in-patient settings. The care plan supported a continuity of care for

patients admitted via the community teams. Patients were invited to attend multidisciplinary team

meetings and were supported to actively participate in the meetings and input into their care and

treatment.

Staff could access external organisations to support patients with communication difficulties. Staff

described creative ways to communicate with patients with communication difficulties. One staff

member told us how the service had provided ear defenders and located a patient in a quieter

room to support them with their sensitive hearing.

Independent advocacy services were available for patients. The service clearly displayed in

communal areas information about how to access the services. Patients told us advocates visited

the wards regularly.

Patients were able to give feedback on the service in a number of ways. Community meetings

were held across all four wards. These meetings provided an opportunity for patients to express

their views. The trust had a service user engagement strategy and this promoted the recruitment

of volunteers who had experience of using services. The service supported volunteers. Maple and

Endcliffe wards had volunteers during this inspection. Volunteers worked directly with patients in a

number of activities. They also supported patients to complete patient questionnaires to identify

service improvement ideas.

Patients could provide feedback upon discharge by completing ‘care opinion’ and the friends and

family test. This feedback was closely monitored by the trust.

The service user engagement team at the trust had been instrumental in gaining feedback from

service users relating to the design and development of the Longley Centre as a city-wide location

for all adult acute and psychiatric intensive care unit provision within the trust. This involvement

had led the trust to change the design of the new health based place of safety to include individual

outdoor space for each bedroom within the suite.



The service had a positive approach to involving families and carers. A monthly carers meeting

was available for families and carers to attend; one carer confirmed they had previously attended

this. Information was on display regarding carers’ week in June 2018.

At the point of a patient’s admission, consideration was given to carers and families. Of the 17

care records reviewed, nine records had evidence of family or carer involvement and one record

stated the patient did not want any family involvement. We saw evidence of one referral for a

carers’ assessment. Families and carers were actively encouraged by the nursing and medical

teams to be part of their relative’s care. Regular appointments were available for families and

carers to attend the wards to discuss patients’ care and treatment with the doctor and nurses. Staff

told us these appointments were used regularly and were a valuable source of information and

additional support for patients.

However, feedback from carers regarding the care and treatment of patients was mixed, with poor

communication from the wards was the most common issue raised. Carers told us responses to

requests for information were slow, and that they did not always receive feedback about issues

raised or share information about care and treatment. Two carers told us they we not informed

when their family member was transferred and admitted to the general hospital.

Carers could provide feedback about the service in person, or via the telephone or the internet.

However, four of the eight carers we spoke with did not know how to provide feedback to the

service. Carers knew how to make a complaint and felt able to do so. Two carers told us they had

made informal complaints on the ward, these were managed quickly and with a satisfactory

outcome.




Bed management

The core service had bed occupancy numbers above 85%. The Royal College of Psychiatrists

recommends bed occupancy rates of 85% or less, stating that lowered bed occupancy rates

enabled local timely admissions and provides optimal support for patients.

The service aimed to ensure there was always a bed available when patients returned from leave.

Ward managers told us the contingency plan would be to extend leave if it was safe to do so or

arrange a ‘sleepover’ on one of the other acute wards, this meant patients were moved onto other

wards for non-clinical reasons. We discussed this with the trust and no specific information was

recorded in relation to this. The current system used did not differentiate between the use of a

leave bed or surge bed for an admission. Maple, Stanage and Burbage wards had ‘surge beds’.

This meant the male and female bays on each of these wards were typically used by just two

patients, however, they were used to their four-bedded capacity when demand was high. The trust

had in place an escalation protocol to follow in circumstances when the surge beds were used

which had been ratified by the trust board.

The trust provided information regarding average bed occupancies for four wards in this core service between 1 March 2017 and 28 February 2018. We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the time period that was covered.



Burbage Ward 95.24-120.05

Burbage Ward plus detox 87.54-105.94

Maple Ward 91.27-111.01

Stanage Ward 89.81-105.73

Endcliffe Ward 70.67-99.64

With the exception of Endcliffe, all wards had average bed occupancy above 85% for all months reported. We examined the dashboard for all wards, from November 2017 until March 2018, both Burbage and Stanage wards were consistently above 100% bed occupancy. Maple ward was above 100% bed occupancy from January 2018 to March 2018. Ward managers confirmed that surge beds were regularly used to meet the demand for new admissions. Capacity and flow within in-patients services was proactively managed. Weekly bed management meetings were held and attended by doctors, discharge co-ordinators, ward managers, home treatment team doctors, crisis house staff and senior managers. This meeting provided the opportunity to examine closely the anticipated requirements from the community and bed pressures on the wards. Ward managers confirmed they also received twice daily emails from the bed manager, providing ‘live data’ on capacity and flow. This information was also shared with discharge co-ordinators. Staff we spoke with told us admissions continued to increase, acuity remained high and demands on staff were constant. Some staff we spoke with felt the reconfiguration of community services had impacted on the inpatient service. Senior managers acknowledged the increase in demand on


services in the last three months and were keen to understand the reasons for this and the impact. Work had commenced to examine closely the data, though this was still in the early stages. Staff supported patients during transfers between services. If a patient required more intensive

care there was access to a psychiatric intensive care unit within the trust. Endcliffe ward provided

ten beds available to both male and female patients. This was a city-wide service. The service

would gate keep their own admissions to ensure patients’ needs were appropriate for the service

and this was completed by the multi-disciplinary team.

The trust provided information for average length of stay for the period 1 March 2017 and 28 February 2018. Endcliffe ward had the highest average length of stay at 69 days and Maple ward the lowest average at 15 days. The trust monitored the average length of stay through clinical governance meetings. Between November 2017 and March 2018, Burbage and Stanage wards average length of stay was consistently above 31 days, and Maple was below 31 days. To understand this more, a senior nurse worked with the wards to examine admissions and discharges.



Burbage Ward 54.27

Maple Ward 15.25-48.10

Stanage Ward 22.61-42.82

Endcliffe Ward 22.00-69.00

This core service reported 59 out area placements between 1 March 2017 and 28 February 2018. As of 28 February 2018, this core service had one ongoing out of area placements. There were two placements that lasted less than one day, and the placement that lasted the longest amounted to 86 days. All of the out of area placements were due to alternative providers better suiting the service users care or personal needs. We requested further information from the trust in relation to out of area placements. The trust confirmed a number of reasons for these placements. These included requests from families for care closer to home, Sheffield registered patients repatriated back to local services and staff members requesting care outside of the trust.

Number of out of

area placements

Number due to

specialist needs

Number due to

capacity

Range of lengths

(completed

placements)

Number of ongoing

placements

59 59 - 1- ongoing 1

This core service reported 15 readmissions within 28 days between 1 March 2017 and 28 February 2018. Seven of readmissions (47%) were readmissions to the same ward as discharge. The average number of days between discharge and readmission was eight days. There were no instances whereby patients were readmitted on the same day as being discharged.

Number of

readmissions (to any

ward) within 28 days

Number of

readmissions (to the

same ward) within

% readmissions to

the same ward

Range of days

between discharge

and readmission

Average days

between discharge

and readmission


28 days

15 7 47 2-23 8


Between 1 March 2017 and 28 February 2018 there were 636 discharges within this core service. This amounted to 79% of the total discharges from the trust overall (804). Maple, Stanage and Burbage wards had a discharge co-ordinator who was a band six nurse. This

role enabled the service to address barriers to possible discharge and assisted in accessing most

appropriate discharge support packages of care. Staff we spoke with told us that discharges were

discussed with patients at the earliest opportunity in their care. We reviewed 17 care records and

14 records demonstrated that staff had discussed and planned for a patient’s discharge.

Discharge co-ordinators worked closely with community teams to ensure care packages were

timely, co-ordinated and appropriate to patients’ needs.

We reviewed discharge data from each ward between March 2018 and May 2018. There had

been a total of 55 discharges in March 2018, 59 in April 2018 and 66 in May 2018.

There were 27 delayed discharges between 1 March 2017 and 28 February 2018, 22 of which were on Maple ward. We reviewed board paper minutes from January 2018 and it was evident that work was ongoing to

monitor delayed discharges effectively. We requested further information from the trust in relation

to the delayed discharges from Maple ward. Of the 22 delayed discharges reported for Maple

Ward between 01/03/2017 and 28/02/2018 these related to 12 individual patients. Reasons for the

delayed discharge of these 12 patients included; three patients awaiting a care home placement,

nine patients a care package in their own home, and one patient awaiting public funding.


With the exception of Endcliffe ward, all ward environments presented challenges to both staff and

patients. These included the availability of rooms and layout of the ward. All patients on Endcliffe

had individual bedrooms. Maple, Stanage and Burbage wards had individual bedrooms and

dormitory style accommodation. Dormitories could accommodate up to four patients, the trust

attempted to maintain a maximum of two patients in dormitories at any one time to promote the

dignity and privacy of patients. However, between January 2018 and March 20118, all three wards

have consistently had bed occupancy over 100%, this meant ‘surge beds’ were used in each

dormitory. Dormitories were of a traditional layout and bays were screened by privacy curtains. All

dormitories had toilet and shower facilities.

Patients that had individual bedrooms were able to personalise these, although we observed that

most were bare in appearance. All patients could safely store their possessions.

The service had a full range of facilities and equipment to support treatment and care. These

included fully equipped kitchens for patients to use to develop their skills for daily living and meal

preparation. Other rooms available included television lounges, quiet rooms and activity rooms.

Patients at the Michael Carlisle Centre had access to an onsite gym. Maple ward had a ward

based gym and Endcliffe ward had access to various outdoor physical activities such as football,

cycling and basketball. Each ward had access to outside space, patients could access this freely.


Stanage and Burbage wards had small flagged areas but outdoor furnishings were minimal and

seating was limited. The trust were completing work to extend the outside space available to

patients.

Maple and Endcliffe wards had dedicated visitor rooms located off the ward. Stanage and Burbage

wards did not have a dedicated visits room due to the limited space on these wards. Most rooms

were multi-purpose and staff told us visits would go ahead on the ward, including in patient

bedrooms and in the occupational therapy department.

All patients could make private telephone calls. Mobile phones were not restricted and patients

could use their own mobile phones or the ward portable telephone if required in private.

Hot and cold drinks were available twenty-four hours a day. A variety of healthier snacks were

available to patients, including fruit. Patients at the Michael Carlisle Centre and Longley Centre

were complimentary about the quality of food.

• The 2017 Patient-led assessments of the care environment (PLACE) score for ward food at the locations scored better than similar trusts.


Longley Centre



MH - Mental health crisis services and health-based

places of safety.

94.4%






problems.

97.5%

Trust overall 96.4%



Patients were supported to maintain contact with their community, families and carers. Care and

treatment pathways included access to section 17 leave. Patients could utilise leave independently

or if required, with the support of staff. Staff and patients told us leave was essential for

maintaining community contact and achieving recovery goals. Patients had the opportunity to

explore employment and education activities, this was individually based and determined by the

acuity of each patient. We saw evidence in some care records of discussions with patients

regarding accessing higher education and engaging in voluntary work following discharge from

hospital.

The occupational therapy team were key to driving and maintaining a patients’ engagement with

their community and that activities were meaningful and linked to patients’ recovery goals. The


trust had links with community based organisations that provided creative opportunities that

promoted health and wellbeing.


All wards had disabled accessible bedrooms and bathrooms with handrails to assist in the use of

the bath and toilet.

During the inspection, we saw information on display across all wards for patients, including

information about how to complain, how to contact the Care Quality Commission and the

independent mental health advocacy service. Information was also available on a variety of

physical health and wellbeing topics, including smoking, use of illicit drugs and alcohol. Staff told

us that information could be easily obtained in different languages and formats via the internet.

Stanage ward had a useful electronic patient information store. Information was available about all

aspects of care and treatment and we observed patients using this during this inspection. The trust

had a contract in place to provide interpreting services. Staff told us they could readily access

interpreters for patients where English was not their preferred language. We saw that interpreters

had attended the wards to support patients during multi-disciplinary meetings and whilst in

seclusion. Staff could access a telephone interpreting service and the internet to print leaflets in

different languages.

Patients had access to spiritual care and could also access a range of spiritual support on the

wards. A variety of religious books and quiet areas were available for patients to use. Private

washing facilities were also available for patients. We spoke with a member of the pastoral team

and they were complimentary about the trusts commitment to spiritual care. The trust worked in

partnership with a number of local organisations to support specific ethnic groups, these included

the Somali and Asian communities. The service had identified a pathway to refer patients into the

gender identity service where this was appropriate.


This core service received 14 complaints between 1 March 2017 and 28 February 2018. One was

upheld, four were partially upheld and nine were not upheld. No complaints were referred to the

Ombudsman. Four complaints were related to discharge and one complaint was made in relation

to an alleged assault.

The number of either partially or fully upheld complaints reported during this was lower than the 23 reported at the last inspection.

Total Complaints Fully upheld Partially upheld Not upheld Referred to Ombudsman Upheld by Ombudsman

14 1 4 9 No No

Complaints about this core service were low. All wards displayed information on how to complain

and provided fast track complaint forms on each ward. Ward managers we spoke with were

confident in the mechanisms available for patients to complain. The majority of patients we spoke

with were aware of how to complain and were confident to do so. Staff told us they were


encouraged to manage concerns raised by patients or escalate if required to the ward manager.

Most staff felt confident in dealing with a patient complaint. Of the 18 patients we spoke with

during this inspection, two patients had made complaints. One patient was satisfied with the

response and felt the issue had been resolved, the other patient was dissatisfied.

This core service received 87 compliments during the last 12 months from 1 March 2017 and 28




Leadership

The acute and psychiatric intensive care wards formed part of the crisis and emergency care

network. The trust had recently completed a restructure of the organisation that had seen changes

in the leadership of services. The new structure had been operational from April 2018. The trust

had leaders at all levels with a variety of skills, knowledge and experience. Senior managers we

spoke with were relatively new to their posts but were established within the organisation and had

a good understanding of the service they managed.

Ward managers had different levels of experience. Of the four wards, only Endcliffe and Burbage

had substantive wards managers in post. At the time of our inspection, the remaining two wards

had acting or temporary managers. All ward managers spoke positively about the organisational

and peer support available to them.

Staff told us immediate line and operational managers were visible and supportive. Ward based

staff spoke positively about their leaders, felt supported and listened to. Managers at all levels

were committed to delivering high quality care services but were candid regarding the progress

due to the staffing pressures, bed occupancy levels and environmental challenges.

The trust supported the development of managers and key staff networks, such as the BME staff

network group supported learning opportunities.

Vision and strategy

Staff knew and understood the trust’s visions and values. Extensive information was visible on

wards and available on the intranet. Patient information, including leaflets and posters clearly

reflected the values of the organisation. Interactions between professionals and with patients,

demonstrated the commitment staff had to delivering care based on the trusts vision and values.

There was a clear connection between the senior leaders’ vision and strategy and how this

translated into the delivery of care on the wards. Staff were focussed, worked inclusively with

patients and were driven to provide the best possible care.

The approach taken by the trust in the development of the Longley Centre clearly demonstrated

how ambition and partnership working underpinned this key service development. The trust

consulted patients, carers, staff and key stakeholders in its development.

Culture

Managers at all levels promoted a culture that supported and valued staff. Staff spoke with genuine

warmth about their teams and immediate managers. Staff supported each other within the service

and this made a positive difference to staff. Lines of communication were open and honest within

the service and staff felt listened to. Staff reported strong working relationships with the

multidisciplinary team. We saw that staff were committed to their roles and there was resilience in

teams that enabled staff to manage the daily challenges of providing care.

All staff we spoke with felt able to raise concerns without the fear of retribution. Staff were familiar

with the trust whistleblowing policy and were confident in using it. The trust’s freedom to speak up

guardian had been used by the service. Staff had raised concerns regarding staffing issues and

increased acuity of patients. This process allowed open and honest conversations with staff,


examining options and possible solutions to these concerns. The service’s staff sickness and

absence rate was similar to that of the provider. Staff had access to support for their physical and

emotional wellbeing, the trust participated in the mindful employer and workplace wellbeing

schemes. Staff could access support following incidents through the psychology department.

The trust celebrated staff success through its annual recognition and achievement awards.

During the reporting period, there were no cases where staff had been either suspended, placed under supervision or were moved to a different ward.


Governance

The service monitored and reported on a range of key performance indicators such as length of

stay, discharge and re-admissions. Senior managers attended regular patient safety meetings with

colleagues from across the emergency care network to understand current themes and issues.

Therefore, managers were aware of key areas of improvement within the service, such as staffing

levels and bed occupancy levels. The trust had taken some action to address these issues,

however these remained a concern at the time of this inspection. The service also had processes

in place to monitor the performance of wards and a programme of audits; however these were not

always consistent or effective in implementing change.

The trust completed annual risk assessments of the environment which included ligature risks and

fire. None of the wards reviewed the ligature risk assessment following a serious incident in the

service and blind spots had not been identified on most wards. Annual fire risk assessments

completed in March 2018 were not available on wards for staff to use in June 2018.

Staff could not regularly access clinical supervision and the recording of all elements of

supervision was poor. Although supervision was discussed at clinical governance meetings, there

were no clear plans of how to improve this.

The recording of controlled drugs and labelling of patient specific medication was not sufficient.

We saw gaps in audits for emergency medical equipment and fridge and clinic room temperatures.

Systems and process in place did not identify the issues in relation to medical reviews and

physical observations following episodes of seclusion and rapid tranquilisation, or the issues with

exit care plans following seclusion. Section 17 leave was cancelled due to staffing, the trust did not

have a system in place to record and monitor the frequency of this. The trust did not have

arrangements in place to monitor when no bed was available following section 17 leave on the

ward, including the use of surge beds, sleepovers and extending section 17 leave.

Visiting procedures were not robust or sufficient to safeguard children and appropriate action was

not taken following an incident, nor was the process for visitors reviewed to identify any learning or

potential changes to the procedures.

Business meetings occurred frequently on all wards, however there was no standard agenda and

minutes were handwritten. Not all wards recorded attendance or action to be taken. A

standardised approach was taken in monthly governance meetings on each ward, however

recording of discussion, outcomes and actions were inconsistent.

However, systems and processes were effective at ensuring staff were trained and appraised, the

use of restrictive interventions was low, and staff understood the Mental Health Act and Mental

Capacity Act and the application of the Acts was consistent.


The trust had a clinical effectiveness team that was responsible for the day to day management of

National Institute for Health and Care Excellence implementation and assurance process. This

group reported to the clinical effectiveness group who had responsibility for the oversight and

monitoring of activity. This approach supported the trust in meeting its overall responsibilities in

relation to implementing national guidance.


Managers discussed the risk register at quarterly performance review meetings within the crisis

and emergency care network. All wards had a local risk register, these were reviewed regularly at

monthly clinical governance meetings. We reviewed the local risk register and items included

staffing, risk of violence and aggression and harm to service users on Section 17 leave.

The trust had business continuity plans in place that staff could refer to in emergency situations.


Team managers had access to information to support them with their management role. This

included information on the performance of the service, staffing and patient care. Information

governance officers collected data to inform the service on performance, quality and safety. This

included information on mandatory training, supervision, audit activity, restrictive interventions and

service user feedback. Following the restructure into the crisis and emergency care network,

governance arrangements had altered and systems were being aligned. Governance dashboards

were developing to reflect these changes.

The effective use of these systems enabled the service to identify issues in recording the

frequency of rapid tranquilisation. Governance officers escalated this issue and contingency plans

were put in place to ensure accurate information was used to monitor restrictive interventions.

Staff had access to the equipment and information technology needed to do their work. This

included the use of electronic tablets to accurately record patient observations. The trust used

information technology to support care and treatment through electronic care records and

prescribing. Confidentiality was maintained through password protected access.

Engagement

The trust engaged positively with staff, patients and carers. Up to date information was

available through a number of mechanisms.

Staff and patients had access to information on the ward. Information boards were on display

on each ward and Stanage ward had access to an electronic patient information store. The

availability of volunteers within the service was an additional way patients could obtain

information and express their views. Staff and patients had access to the trust website and

staff could access the intranet for information. The trusts website was informative, up to date

and provided extensive information.

Feedback from patients and carers about the service was obtained through community

meetings, carers’ forum, and managers told us they monitored the care opinion survey online.

The trust worked in partnership with community organisations to promote recovery, health

and well-being.





Maple ward continued to be involved in the microsystems work of the trust, an approach involving senior colleagues from the crisis and emergency care network supporting innovation and change on the ward.

This core service had representation as an executive member of the national association of psychiatric intensive care units. This supported learning and practice in this specialised area of care.

In June 2018 the trust were successful in winning a national award for improving patient safety and experience through the RESPECT training programme.


Community-based mental health services for older people


Location site name Team name Number of clinics Patient group (male,

female, mixed)

Fulwood House Memory Service 39 clinics Mixed

Fulwood House

Dementia Rapid

Response and

Home Treatment

Teams,

48 Mixed

Fulwood House

Functional

Intensive

Community

Service (FICS)

0 Respond to people in

crisis Mixed

Fulwood House

Older Adult

Community

Mental Health

Teams

0 Respond to people in

crisis Mixed


Safe and clean environment

All the community teams for older adults were in the same building. Although it was not routine for

patients to come to the building for appointments this did sometimes occur. The building was

clean, tidy and very well maintained. There was clear signage outside of the building so that

people visiting for the first time knew they were at the right location. The reception area was bright

and welcoming with lots of up to date information available for patients and carers. All rooms

where patients were seen were fitted with nurse call alarms. These were in the form of a push

button which sounded out in reception. Staff were able to explain to us how they responded once

the alarm sounded although this rarely happened. All staff we spoke with told us that if a patient

was known to be high risk they would be seen in the room that could be observed from reception

and the interview would take place with two members of staff.

There was one clinic room that was shared by the community teams. This contained all equipment

that the teams needed to carry out physical health checks. There was only a small amount of

medication stored on the premises relating to a few patient own medications that were being used

by the dementia rapid response team. This was all stored correctly and labelled. The clinic was

clean and tidy and equipment in the room was cleaned and labelled. There was however, a

physical health bag that staff used for doing physical health checks on visits to patient homes. We

found that although there was a schedule in place for this to be cleaned every Sunday, it had not

been signed for since January 2018. There was also some out of date equipment such as wipes

for cleaning. However, this was low risk equipment such as blood pressure cuffs, thermometer and

weighing scales and the equipment did not look visibly dirty. We raised this immediately with the

team manager and this was sorted out whilst we were still on inspection.

Safe staffing


Staffing levels were adequate to meet the needs of the service. At 31 March 2018 there were six

vacancies, however, on the inspection we found this had improved and there were three

vacancies across the two teams we visited. The trust had a rotational post system in place

whereby staff could choose to go on a rotational contract where they would move around different

services to learn new skills and cover gaps in staffing. Therefore, the vacancies in the community

teams that were created by staff being successful in securing a secondment to a higher band were

covered by rotational staff.

Bank and agency staff were not routinely used. If cover was required then staff within the team

would do a bank shift to cover for gaps in staffing. This meant that staff covering shifts always

knew the patients they were visiting. Between May 2017 and March 2018 there were 82 bank

shifts across all of the community teams, this equates to around 7 per month. Agency staff were

never used, due to the nature of the service it was important that people visiting patients in their

own homes knew the patient history and needs well.

Definition






8.4 N/A


8% 13%






8% 5%


6% 5%








Bank and agency Use



February 2018 82 N/A


(Qualified Nurses)

1 March 2017 and 28

February 2018 0 N/A




1 March 2017 and 28

February 2018 1 N/A



1 March 2017 and 28




1 March 2017 and 28

February 2018 0 N/A



1 March 2017 and 28

February 2018 4 N/A


This core service reported an overall vacancy rate of 13% for registered nurses at 31 March 2018. This had reduced to 7% by the time of our inspection.

This core service reported an overall vacancy rate of 0% for registered nursing assistants.

This core service has reported a vacancy rate for all staff of 7% as of 31 March 2018.

Staffing levels were established by the team analysing the amount of referrals they receive The dementia rapid response team had formed when the trust reduced the number of inpatient beds for the area with a view to keeping people with dementia in their own homes rather than being admitted into a hospital bed. Staff from the wards were moved to that team. There were enough staff that had relevant experience in caring for older adults to manage the teams caseloads.

The average caseload for the community mental health team was around 30 per staff member and around six for the dementia rapid response team. The community mental health team monitored staff caseloads using a red, amber and green rating system and weighted staff caseloads accordingly. Patients who were rated red were more complex and would take more of the staff members time, therefore staff would be allocated fewer amber and green patients. Likewise, if a staff member had more amber and green patients they would have a higher caseload. In the dementia rapid response team staff only held around six patients on a caseload. This was due to the fact that patients under this team were in crisis and could be having up to daily visits (more regularly if staff were supporting patients with medication). Staff in the dementia rapid response team would work with patients for more intense but shorter periods than the community mental health team.


Team Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Functional

Intensive

Comm

Serv

0 9 0% 1 3 33% 2 15 13%

Rapid

Response 2 15 13% 0 7 0% 3 27 11%

Memory

Service 1 12 8% -1 3 -33% 2 26 8%

Edmund

Road

Central

Admin

0 0 0% 0 0 0% 0 1 0%

CMHT

Managem

ent

2 2 100% 0 0 0% -1 17 -6%



Core

service

total

5 38 13% 0 13 0% 6 86 7%

Trust total 32 433 7% 15 353 4% 68 1339 5%


There are data issues with the bank and agency information as the shifts filled totals are more than the available shifts. We therefore cannot report on the proportion of shifts filled for this core service.

Team Available shifts Shifts filled by

bank staff

Shifts filled by

agency staff


bank or agency

staff

Dementia Rapid

Response and Home

Treatment Teams,

0 5 0 1

Functional Intensive

Community Service

(FICS)

0 77 0 0


Trust Total 32,394

4977

(15%)

7252

(22%)

900

(3%)


There are data issues with the bank and agency information as the shifts filled totals are more than the available shifts. We therefore cannot report on the proportion of shifts filled for this core service.

Team Available shifts Shifts filled by

bank staff

Shifts filled by

agency staff

Shifts NOT filled

by bank or agency

staff

Dementia Rapid

Response and Home

Treatment Teams,

0 24 0 3

Functional Intensive

Community Service

(FICS)

0 35 0 1



(37%)

5623

(9%)

1760

(3%)


This core service had 8.4 (8%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 10% reported at the last inspection.

Team Substantive staff Substantive staff Leavers Average % staff leavers

Edmund Road Central Admin 0.9 0.4 22%

CMHT Management 45.7 6 13%


Team Substantive staff Substantive staff Leavers Average % staff leavers

Memory Service 23 1 4%

Rapid Response 23.5 1 4%

Functional Intensive Comm Serv 13.2 0 0%


Trust Total 1351.6 129.6 8%

The sickness rate for this core service was 6% between 1 February 2017 and 31 January 2018. This was similar to the sickness rate of 7% reported at the last inspection.

Team Total % staff sickness

(at latest month)



Rapid Response 15% 9%

Functional Intensive Comm Serv 11% 7%

Memory Service 10% 6%

CMHT Management 3% 5%

Edmund Road Central Admin 0% 2%


Trust Total 8% 7%

Medical staff

The service employed a team of psychiatrists and junior doctors who were routinely available

across the service to support the medical care of patients. The medical staff we interviewed spoke

positively about the training opportunities available to them. The dementia rapid response team

who worked up until 8pm and at weekends had access out of hours to an on call doctor system,

which was staffed by a junior doctor and a consultant psychiatrist.

Medical locum information was not provided for this service.

Mandatory training

The compliance for mandatory and statutory training courses at 28 February 2018 was 90%. Of the training courses listed two failed to achieve the trust target and of those, zero failed to score above 75%.

During our inspection, we reviewed this and found that the two courses that were below the trust target when the trust submitted the evidence were now above the trust target of 80%. This meant that most of the staff were provided with the training to carry out their role on an ongoing basis.


Key:





Trust target %

Trustwide mandatory/ statutory training total %









Falls) 95% 80% 97%




Rapid Tranquillisation 90% 80% 88%















We reviewed eleven care records across the two teams. We found that risk was assessed for

every patient. This was completed on triage for the dementia rapid response team and then in

more detail on the initial visit. For the community mental health team, a risk assessment was

expected to come with every new referral and then the team would complete another risk

assessment on the first visit to the patient. Risk assessments were reviewed at every visit and this

was documented in the patient record. If risks had significantly changed then a new risk

assessment would be completed and a new risk management plan commenced.


Staff completed crisis plans which included the relevant telephone numbers of who to contact in

an emergency. There was a dementia helpline for patients who had been diagnosed under the

memory clinic at the service. This meant that if a carer was struggling in any way they could ring

this helpline directly and receive advice and support over the telephone for the patient. This was

also a route for a direct referral into the dementia crisis team to eliminate the carers having to go

through various different services to get help.

Staff were able to prioritise service users who were experiencing a deterioration of their mental

health. This was due to manageable caseloads and a supportive team approach. This meant that


for patients in crisis the team could visit a number of times per day to enable that person to stay at

home. This included supporting with medication although this remained the responsibility of social

care teams, the team were able to support this short term if it prevented a hospital admission.

There was no waiting list to be assessed by the service or allocated to worker. The community

mental health team aimed to see all new referrals within two weeks and the dementia crisis team

within 48 hours. However, his was usually always met sooner unless the person needed to wait

longer for example to accommodate a relative attending the initial visit.

Safeguarding



This core service made 65 adult safeguarding referrals during the 12 months prior to 30 April 2018.

All staff were trained in safeguarding up to level 3. The training rate was 90%. Staff had a good understanding of safeguarding and what type of things they would report. Staff knew the internal procedure for reporting via the incident reporting system and who to ask for advice within the trust. We were able to review examples of incidents staff had referred to the safeguarding team for example, suspected financial abuse.

There was a lone working policy for staff working on the community. This included the use of electronic diaries so that the person who was the coordinator on each shift knew where each member of staff was and when they were due back. Staff were aware that they needed to leave mobile phones switched on at all times (turned to silent during home visits). If a patient was deemed as higher risk then staff would always visit in twos.



Patient information was stored on a secure electronic system that required a password to access

it. The system had been in place for a number of years and staff found this easy to navigate. Staff

had access to part of the primary care records and hospital records for their patients. This meant

they could access blood results, x-ray and scan reports and discharge summaries for stays in the

acute hospital setting. Staff reported they found this invaluable for keeping up to date with the

physical health needs of their patients.


The service only stored a small amount of patient own medication that was being used by the dementia rapid response team. Patients in the community who required depot medication ordered their own and this was kept with the patient until it was dispensed. For patients who needed


support, family or carers would assist with ordering and collection of depot medication. If medication was prescribed by the consultant psychiatrist there were prescription pads kept at the service. Doctors were aware to only carry a small number of these with them on visits and the full prescription pads were securely stored on the premises.


Providers must report all serious incidents to the Strategic Information Executive System (STEIS) within two working days of an incident being identified. Between 1 March 2017 and 28 February 2018 there were two STEIS incidents reported by this core service. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period. We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with STEIS. The number of serious incidents reported during this inspection is the same as the two reported at the last inspection. The team managers were able to talk to us about serious incidents that had occurred in the service. This included access to the full investigation and to demonstrate how learning was shared across the community teams. For example, following a suicide the team had reviewed the incident as part of the trust investigation process. This meant that the senior managers and staff involved in the incident were able to have input into the investigation report. Once complete the report and learning was fed back to the wider team (and other community teams) in order for the learning to be shared. Although it was found the team had done everything possible to care for the patient they were still able to discuss how they could do things differently in the future including better communication with other organisations such as local pharmacies. For all incidents learning was fed back via team meetings or if necessary at individual staff supervision where learning was for an individual staff member. The trust used an electronic incident reporting system and all staff had access to report incidents.

Senior members of the team were able to access to review and sign off incidents. Staff were able

to tell us what type of things they would report as an incident, for example, medication errors,

deaths, breaches of confidentiality and physical health emergencies.

Staff told us that they received feedback from incidents during staff meetings and individual

supervision. We were able to review some of the minutes from meetings and found this to be the

case.

Staff were aware of their responsibilities under duty of candour and the need to apologise in the form of a letter if something went wrong. Staff were open an honest with patients and told them about more minor errors as well as serious ones. Patients were always offered and apology if an appointment needed to be changed at short notice although this was rare.


Type of incident reported on STEIS OA

CMHT

SW

Dementia

Rapid

Response

South

Total

Apparent/actual/suspected self-inflicted

harm meeting SI criteria 0 1 1


Medication incident meeting SI criteria 1 0 1

Total 1 1 2







We looked at eleven records across the two teams we visited. We found that all patients had a

comprehensive assessment of their needs. This included assessment of physical health, reason

for referral, past history, presenting problems and social factors. We found that care plans were

completed to a high standard and showed a good level of involvement from patients and carers.

Where possible care plans were shared and left with the patient. However, for some patients with

more severe cognitive impairment this would be kept either with family or at the community team.

If patients refused a copy of their care plan this was documented clearly and further attempts

made to explain to the patient about their care plan during home visits.


We observed staff following national institute for health and care excellence guidance for the

prescribing of medication. Both teams were aware of the need to reduce antipsychotic prescribing

for patients with a cognitive impairment. There were measures in place to monitor those on

antipsychotics and lithium including checklists for physical health checks prior to commencing

medications and during to monitor.

The team also had therapy dolls for people with dementia who showed symptoms of anxiety or

distress. The team had recognised that some families may find this distressing to see their relative

effectively playing with a doll. Therefore, the team kept journal articles with the dolls so they could

show patients families the evidence base around the use of this type of therapy.

Physical health was monitored by the team although interventions were carried out by the GP. The

team would check weight and blood pressure during visits if required and some patients were on

weekly weighing regimes if there were concerns about nutritional intake or weight loss.

There was access to psychological therapies and psychologists and trainee psychologists were

based within the team. This meant that referrals could be actioned quickly and there was no wait

for psychological therapies. Psychologists offered both group and one to one sessions with

patients and carers. These included, anxiety management and depression groups and 1-1

therapies with carers for people with dementia. The teams worked together well to facilitate this,

for example arranging visits to the patient whilst the carer attended psychology sessions.

Outcomes were measured using the health of the nation outcome scale and this was completed

on initial visit and throughout the time the patient was under the community team in order to

measure the effectiveness of the care the patient was receiving. There were other tools used

dependent on the patient’s diagnosis for example depression and anxiety scales.

The teams used information technology in a number of innovative ways to maintain independence

and reduce confusion for patients with a memory problem. This included the use of “just checking”

an activity monitoring system that allows people to remain in their own homes for longer by

showing the team their capabilities on a day to day basis and where extra support was needed.

They also had an advanced version of the system that allowed them to attach sensors to items

such as the fridge, kettle and tap to show if sequencing was maintained in day to day activities.

For patients who liked to walk out but sometimes got lost, the team also had a “buddy system”

device. This was effectively a GPS tracking device which allowed a family member to monitor

where the patient walked to without having to follow them or even stop them going out. Lastly for

patients who had trouble remembering who family members were the team used a photographic


diary where they could work with the patient and their families and record who the family member

was and things they liked to do so when the page was turned it played the memories back. This

not only helped to reduce agitation and confusion but it gave the families a nice activity to do

together with the person with dementia.

Staff supported social interventions such as support with housing or benefits. Staff identified

concerns during the initial assessment process and referred to other external agencies.

This core service participated in the following clinical audits as of their clinical audit programme in

the 12 months leading up to the submission of the provider information return.


completed


audit

Collaboration

with Primary

Care Clinicians

Service users

on CPA

Provider









solution.

Record keeping


Provider




staff on use of



relevant policy.

Audit of risk

assessments

2016/2017

Trust wide Provider







in 2017/18.

Audit of risk

assessments

2017/2018

Trust wide Provider


Audits of care

plans Trust wide

Provider

wide Clinical audit

January

2018


small scale audits.


teams.

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG43

Transition from

children’s to

adults’ services

for young

people using

health or social

care services

Trust wide Provider


Findings fed into






transitions

Assessment of

National

Institute for

Trust wide Provider

wide Clinical audit

September

2017



future


Health and Care

Excellence

Guidance: NG13

Workplace

health:

management

practices

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG58

Coexisting

severe mental

illness and

substance

misuse:

community

health and

social care

services

Trust wide Provider

wide Clinical audit

December

2017

Action plan under

development

We also found that regular clinical audits took place to monitor things such as care records and

collaborative care planning. This included checking assessments, risk assessments care plans

and other documentation was available and up to date.

Staff told us that the results of audits were fed back during staff meetings, or if necessary in

individual supervision. We saw evidence of this in the minutes of staff meetings and supervision

records.


Each team consisted of nurses, consultant psychiatrists, occupational therapists, psychologists,

support worker, administration staff and team managers. There were no social workers as part of

the team; patients with identified social care needs such as those requiring residential care funding

assessments were referred for social work input via the local authority. Staff who worked in the

team had worked there for many years and were skilled and knowledgeable about the field they

worked in.

We looked at the compliance rates for the community older adult services during our inspection.

Although clinical supervision figures were low across the functional intensive care team and the

rapid response team with an average compliance rate of 59%, staff told us that they felt very well

supported within their team and received regular supervision. We reviewed records that showed

that staff had access to supervision in a number of formats, They were able to access formal

supervision with their supervisor and could access reflective practice sessions facilitated by the

psychology team as a group or individually. Reflective practice sessions happened on a monthly

basis although these were not recorded as formal supervision sessions. Staff who were from a

profession other than nursing, for example, psychologists and occupational therapists were able to

access clinical supervision via an approved list of supervisors from their own profession. The trust

had recently introduced an electronic recording system for clinical and managerial supervision as

they had recognised the recording of supervision was not always captured as it was being

delivered. This new system showed who had received supervision, the date, whether it was

clinical or managerial and when it was next due. From the time the new system was implemented


we were able to see all staff had received supervision in line with the trust target. The managers

had access to all figures and were alerted when this was due for each member of staff. Although

this was a new system we were able to see from previous paper records that staff within the team

were having regular supervision on a monthly basis. Staff told us they felt very well supported in

the team and that they felt able to ask any member of staff for advice regarding their work if they

needed it. The trust also held a complex cases clinic on a monthly basis where practitioners could

bring patients cases with whom they were struggling to the panel and they would offer advice and

support around how to manage the case. Staff had taken more complex cases to this panel and

found it to be helpful.

There was a budget available for staff to apply for specialist training relevant to their role. There

were two members of staff awaiting a start date for the non-medical prescribing course. Other

courses completed by staff in the teams we visited included a masters degree in dementia care at

the local university. Staff told us they were encouraged to develop their knowledge and skills

within the team and were supported to do so by senior staff.

Managers told us that they felt confident to manage staff who were underperforming on their

individual teams. There were no staff that were being performance managed at the time of our

inspection but managers were able to give us examples of when they had done this. They felt

confident they could manage with support from human recourses if necessary.

Most staff had received a recent appraisal which helped them to provide high quality care and help

develop them personally and professionally. The trust’s target rate for appraisal compliance is

90%. As at February 2018, the overall appraisal rates for non-medical staff within this core service

was 96%.



Team name

Total number of


staff requiring an

appraisal

Total number of

permanent non-

medical staff who


% appraisals

Rapid Response 27 27 100%

Functional Intensive Comm Serv 16 16 100%

Edmund Road Central Admin 2 2 100%

CMHT Management 45 45 100%



Trust wide 1495 1440 96%



The rate of appraisal compliance for medical staff reported during this inspection was the same as



Team name

Total number of



Total number of

permanent medical

staff who have had

an appraisal

%

appraisals

CMHT Management 6 6 100%






Between 1 March 2017 and 28 February 2018 the rate across all four teams in this core service was 59%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was lower than the 64% reported at



sessions required

Clinical

supervision

sessions delivered

Clinical

supervision rate

(%)


Older Adult Community Mental Health Teams 202 141 70%

Functional Intensive Comm Service 88 43 49%





Between 1 March 2017 and 28 February 2018 the clinical supervision rate for medical staff was 158%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was higher than the 64% reported at



sessions required

Clinical

supervision

sessions delivered

Clinical

supervision rate

(%)




OA CMHT 12 4 33%




Each team had monthly team meetings that were structured and followed a set agenda. This

covered issues such as risk and governance. The teams were informed about any changes to the

service and feedback was given on incidents.

There were weekly meetings to discuss new referral and allocations for the teams. We observed

one of these meetings for each team and found them to be effective in discussing issues such as

risk and who would be the best practitioner for that particular patient.

The teams consisted of staff that carried out initial referral through to community mental health

teams, memory assessment, crisis care and intensive home treatment. Staff liaised with acute

hospital wards to provide ongoing support to patients being discharged from hospital. Staff within

teams had a shared understanding of each other’s roles and were committed to working together

to ensure patients’ needs were met. This helped to ensure patients were moved through the health

system and received care from the most appropriate team at any given time according to their

needs including when they were in mental health crisis. Staff linked in with the inpatient services

for people who had been admitted informally or detained under the mental health act.


Practice


Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient

and all community staff and renewed every three years.

Staff were able to demonstrate knowledge regarding the Mental Health Act and the guiding

principles. Staff were aware of Community Treatment Orders and how they were implemented and

care planned.

Community Treatment Orders were not frequently used by the teams. There was only one patient

who was subject to a community treatment order and they had recently been recalled to hospital.

We found that all paperwork had been filled in and stored correctly in this case.

Staff could contact a central team to seek advice about the Mental Health Act. Staff knew how to

contact the team.

There was an independent mental health advocacy service available for patients who were

detained under the Mental Health Act. Staff were aware of the service and knew how to refer

service users.






renewed every three years.

The training compliance reported during this inspection was higher than the 56% reported at the last inspection.

Patients of the community mental health teams for older adults were living in the community with a

degree of autonomy and patients' capacity was assumed unless it was indicated otherwise. Staff

had a very good understanding of the guiding principles of the Mental Capacity Act. We found

really good examples of where capacity had been considered and assessed in the care records.

We saw how staff had considered capacity on a decision specific basis for example around things

such as access to finances, moving home or agreeing to go into a care home. We saw evidence

that where patients were deemed to lack capacity to make a certain decision, staff were making

sure that best interest meetings had taken place and decisions were made in the best interest of

the patient.




We observed interactions between patients and staff on five home visits over the two teams. We

also made telephone calls to four patients and carers to ask questions about the team. Staff

showed a kind, compassionate attitude towards patients and their carers. During home visits we

saw staff displaying a genuine and caring attitude towards not only patients but their carers too.

For example, on one visit the patients’ carer had some additional needs that were not the

responsibility of the team. However, the team felt that it was important to ensure that the carer was

fully involved in decisions regarding their loved ones care and planning of how to break news such

as diagnosis with the carer present were well thought out before the visit went ahead. This meant

ensuring that members of other teams outside of the trust were present at the visit to give support

to the carer. On another visit the visiting nurse found that the patients dog was unwell on arrival.

Knowing how important the patients pet was to them in terms of alleviating symptoms of their

mental health problem the visiting team member went above and beyond the call of duty to ensure

that the dog was seen by a local vet in order to ensure the pet was cared for thus maintaining the

patient’s mental wellbeing. Staff had a very detailed understanding of the patients they were

providing care for and whilst maintaining professional boundaries ensured that these needs were

addressed and cared for in a sensitive, caring and empathetic way. Patients we spoke to

commented on this and told us that staff showed a genuine interest in them and their lives not just

their mental health diagnosis. For example, one patient used to enjoy swimming but was unable to

continue to go alone due to their diagnosis. The team arranged for a support worker to accompany

the patient to the local swimming baths to ensure their safety but to also maintain links with their

pre- diagnosis interests and hobbies.

All patients and carers gave universally positive comments about the team. Patients made

comments such as “she gave me a reason to live” and “I couldn’t have asked for anything more at

the worst time of my life”. Staff treated patients as individuals and applied a person centred

approach to their practice. Staff knew the patients extremely well. Staff listened to patients and

were sensitive to their needs establishing a good rapport.

All service user information was stored within the electronic recording system which was safe and

secure.

Involvement in care

Involvement of patients/ Involvement of families and carers

Every patient record we reviewed contained a person centred collaborative care plan. It was clear

that the patients’ voice was captured in the care plan and their views were taken seriously and

recorded accurately. Patients we spoke to told us they were actively involved in their care plans

and were always offered a copy. The trust used the collaborative care planning approach and this

documented the involvement the patient had in their care plan. This ranged from “I do not want to

be involved in this goal” to “I feel like I am taking a lead on my goal. I have written my goal and

practice the steps with very little input and support from staff”. This meant staff were aware of how

involved their patients were in care and could monitor this as an indication of the patient gaining

insight into their illness where possible.

All carers we spoke to were positive about the support they had received from the teams. During

our observed visits, we saw that staff were attentive to the carer’s needs as well as the patients.

Carers we spoke to told us that staff had “gone over and above” what they expected of them and

that they felt supported “all the way through the journey”. Carers were involved in care planning (if


patients agreed) and this enabled the staff to understand the triggers for patients as well as what

helped to calm them down when agitated. Carers we spoke to told us that they felt their opinions

and views on the patient’s care were taken seriously and that they were able to be involved in

things such as care planning which made them feel a true partner in their loved ones care. Carers

told us that the team members were available when they needed them and not just during

appointments. There was a crisis phone line that patients’ carers could ring if they needed support

and advice at any given moment. Carers told us that crisis care plans which directed them to

particular services dependent on the time of day and the nature of the problem made them feel

more equipped to cope in times of a crisis.

There was an active service user group that was regularly attended by around 30 people. The

group had made decisions regarding the service and its development. For example, the group had

identified that the font on the letters sent out from clinic appointments was too small for them to

read. They had a discussion around the best size and colour and these changes were then

applied to clinic letters going forward. When the trust introduced its new vision, senior members of

the executive team at the trust came to the group to explain these to patients and take feedback

and comments on them. The group was named by the service users that attended and was called

“helping each other”. Guest speakers attended each meeting for example the fire service had

attended to give a talk about fire safety in the home, a group called boot camp who support people

if they have an issue in the local community such as street lighting or bin collections. Trading

standards had also attended to talk about new types of scams via email and mobile phones.

Carers and patients were also encouraged to attend a local dementia involvement group that was

organised in partnership with the Alzheimers Society. This was called Sheffield dementia

involvement group or “SHINDIG”. The group met four times per year and aims to encourage

people living with dementia and their carers to share views and opinions on local services and

developments within Sheffield.

Service users took part in interviews for new staff and this was sought via the trust who had a list

of service users who had been through training to assist with this.

Staff were aware of local advocacy services available to service users and carers. Staff knew how

to refer and signpost service users and carers to advocacy services. There was information about

the service displayed in the reception of the building. We saw evidence of when patients had

accessed advocacy for support. One example of this was to support a patient who was moving to

another area and did not have any family/friends to support them with this.

The service sought feedback from patients and carers via an exit questionnaire when patients

were discharged. The results of these were collated annually and discussed within team meetings

and governance meetings to allow staff to reflect and think of ways to improve.



Access and waiting times

Each team assessed service users referred to the service quickly as demonstrated in the figures

below. Patients who needed to be assessed more urgently could be seen the same or next day if

necessary. There was a triage system in place which meant that patients were contacted quickly

in case their situation had changed since referral.

Staff were able to respond quickly to telephone calls and patients and carers we spoke to reported

they were able to get hold of a member of the team quickly when they needed them. Appointments

ran on time and were not cancelled. Patients were offered appointments at times which suited

them and their carers in order for all people important to the patient could attend.

If patients were reluctant to attend or were difficult to engage with then staff would make several

attempts to visit, unplanned visits were carried out if required.

The trust has identified the below services in the table as measured on ‘referral to initial assessment’ and ‘assessment to treatment’.

Name of

hospital

site or

location

Name of

team

Days from referral to initial

assessment

Days from assessment to

treatment Comments,

clarification Target Actual

(mean)

Target Actual

(mean)

Fulwood

House

Older Adult

Community

Mental

Health

Teams

28 N/A N/A N/A

Urgent - 4 hours

Routine - 28days 92%

of referrals in the last

12 months have been

assessed within 21 to

28 days.

Fulwood

House

Dementia

Rapid

Response

and Home

Treatment

Teams,

Triage - 4 hours

Urgent - 24 hrs

routine - as

determined by

triage

N/A N/A N/A

Treatment starts at

point of assessment.

All targets met or

exceeded within last

12 months.

Fulwood

House

Functional

Intensive

Community

Service

(FICS)

Triage - 4 hours

Urgent - 24 hrs

routine - as

determined by

triage

N/A N/A N/A

Treatment starts at

point of assessment.

All targets met or

exceeded within last

12 months.

Fulwood

House

Memory

Service 42 N/A 56 N/A

The local target set for

referral to assessment

is 6 weeks. Local

target set for

assessment to

treatment is 8 weeks.

The service has met

this target over the

last 12 months, and

consistently exceeds


Name of

hospital

site or

location

Name of

team

Days from referral to initial

assessment

Days from assessment to

treatment Comments,

clarification Target Actual

(mean)

Target Actual

(mean)

this target, able to

offer assessment

between 1 - 3 weeks

of referral as

standard. Note

patient choice is taken

into account when

offering appointments

and those outside of

the standard may be

due to specific

requests from patients

or carers.

The facilities promote comfort, dignity and privacy

The building had a full range of rooms to support care and treatment. This included a clinic room

where patients could be examined, interview rooms that were private with obscured glass and

conversations could not be overheard. There were also rooms that could be discreetly observed

by other staff if there was a known risk with a patient coming to the building. Staff told us that

rooms were always available when they needed them and they could use other floors of the

building if they needed to for example a bigger room or smaller room.

Staff were based in an open plan office with staff of different disciplines sitting together. Staff

reported they liked this as they could offer each other advice and support in an informal way if a

colleague wanted to discuss a patient. Senior members of the team also sat in the office so that

staff knew where they were and they were easily accessible by staff.

There was a wide range of leaflets on display for patients and carers who visited the service. This

included information about different mental health problems, local groups and clubs and

information about complaints and how to give feedback on the service. These were all specific to

older adults and included information about third sector organisations. Patients were given

information on how to complain and on local services when visited by community staff.


Staff supported and encouraged people to maintain contact with their families, carers and wider

networks where they wished to maintain this.

There were opportunities for people to engage with the wider community. Local groups included

‘singing for the brain’, where people with dementia and their carers can go and sing along to past

music as a form of reminiscence therapy. There was also a group at the local library where people

with dementia could go to do sport reminiscence. The local leisure centre had a bowling group that

some patients attended and there was also a local allotment that patients were able to attend.

Some of the patients took part in walking football which maintained a healthy lifestyle at a pace

that was manageable for patients with reduced mobility. The teams were also flexible in the way

they worked with patients and would try and tailor therapies to meet patients’ interests. Examples

of this included taking patients to the local swimming baths. The team had recognised that the


need to reach out to male older adults and had sought out a local ‘men’s shed’ group where men

could go and connect with other men whilst being creative and reducing isolation.

There was a local dementia involvement group named SHINDIG (Sheffield Dementia Involvement Group). The group was organised by the Trust in partnership with Sheffield Alzheimer’s Society. The group met quarterly and the focus of the forum was to provide opportunities for people living with dementia in Sheffield (and their family carers) to share ideas, views and opinions on local services and developments.


The service was able to accommodate people’s differing levels of need. There was a slope to enter the building, accessible toilets and there was a stair lift down to the bottom floor. There was dementia friendly signage around the building and there was welcome information displayed in different languages relating to the most relevant languages in the local area.

Staff had access to interpreters and signers to help enable effective communication with people

where required. Staff could undertake assessments gradually and over several sessions to help

allow for extra time where people may have additional communication needs.

The teams had tried hard to reach out to hard to reach communities. They had attended groups for

the South East Asian community, the Chinese community and the Somalian community. During

these meetings staff from the teams had spoken to the attendees about mental health and what

the team could offer in terms of support. They had taken interpreters with them in order to support

communication.


All patients and carers we spoke to told us that they felt comfortable raising any issues they had

with their named member of staff in the first instance. Although they all knew how to complain,

they said they had not had any reason to do so. Service users and carers felt that any complaint

would be addressed appropriately. Staff were aware to raise any complaint to the team manager.

Managers told us they would try and resolve any complaint informally before the formal complaints

procedure. Staff knew there was a complaints leaflet to inform service users and carers of the

complaints.

We were able to see where the team managers reviewed feedback received from patients and

carers. Even though feedback forms were completed anonymously there was space to leave a

name and contact number/address if they wanted feedback from an issue they raised. We were

able to see responses that had been sent out to patients who had done this. The team managers

reviewed all feedback questionnaires annually and used the data to present at the team meetings

to show any themes or trends occurring over the year.

There were low numbers of complaints made by patients and cares. Managers were committed to

looking at complaints and learning lessons. This core service received seven formal complaints

between 1 March 2017 and 28 February 2018. None were upheld and three were partially upheld.

No complaints were referred to the Ombudsman. Three complaints are under investigation and

two complaints were related to patient care.

The number of either partially or fully upheld complaints reported during this was lower than the 23 reported at the last inspection.


Total

Complaints

Fully

upheld

Partially

upheld

Not

upheld

Referred to

Ombudsman

Upheld by

Ombudsman

7 0 2 1 No No


February 2018, which accounted for 10% of all compliments received by the trust as a whole.

During our inspection, we saw lots of examples of compliments to the service displayed

throughout the building in the form of letters and cards from people wanting to show their gratitude

to the service for the care they received.



Leadership

The teams were managed and overseen by experienced professional nursing staff who had

worked there for a number of years.

There had been no staff surveys that directly related to this core service.

Sickness and absence rates were low across the service. Sickness was not due to work related

stress and managers had good oversight of the sickness levels within their teams. Managers used

the trust policy to manage staff who were having higher levels of sickness and felt confident to do

so. There had been no bullying or harassment cases within the service in the last 12 months.

Managers were able to tell us how they would manage this with support from human resources if

needed.

Staff we spoke to were aware of the whistleblowing policy and were able to describe the process

well. Staff felt confident to raise concerns initially with their manager without fear of victimisation.

Staff stated they regularly raised concerns during team meetings and other forums.

There were opportunities for leadership development. The senior members of the team had

completed leadership training and courses around sickness absence and performance

management. Staff reported being encouraged by their managers to attend training courses

outside of mandatory training.

Both teams we visited reported excellent team working and mutual support. Staff were supportive

of each other and valued each other’s contribution.

Staff were aware of the duty of candour policy and were able to describe situations where they

have needed to apologise to service users. Staff confirmed they used an open and transparent

approach when addressing these issues.

Vision and strategy

Most staff we spoke to could tell us about the trust values. These were very similar to the team

vision and values. The values were within the appraisal process so that staff aligned their work

ethics to the trust values.

Senior members of the team felt supported by more senior managers and told us how most of

them had worked in less senior positions within the trust prior to promotion. Less senior staff did

not feel they saw a lot of senior level staff above their own team managers but they felt confident if

they wanted to speak to them this would be easy to arrange.

Culture

During the reporting period, there were no cases where staff were either suspended, placed under supervision or were moved to a different ward.


Morale and staff motivation was high throughout the whole service. All staff we spoke with were

positive about their role and the service they provided. They showed a commitment and dedication

to supporting patients. There was a strong culture of team work and staff worked collaboratively

with each other and partner agencies. Staff morale was positive and the trust was considered to


be a good employer. Staff development was encouraged and discussed during supervision and

appraisal sessions.

Staff respected managers and told us they felt supported. Staff were able to raise concerns

without fear of victimisation and knew how to use the trust whistle blowing process. There was an

open and honest culture and a positive environment for learning from incidents and complaints.

Staffs hard work and successes were recognised. This was through positive feedback in one to

one supervision sessions and through staff awards.

Governance

Mandatory training was all above the trust target of 80% for this core service at the time of

inspection. Managers were able to view their teams training status at a glance on the electronic

system that collates the information. Staff were responsible for booking their own training but

managers would prompt at supervision and team meetings if necessary. Staff had access to the

electronic training record and could check and book training modules.

Team managers were able to monitor compliance with appraisal and supervision. This was done

via the introduction of a new electronic recording system. Prior to this recording was done via

paper records and there was nowhere to record if supervision was managerial or clinical. The new

electronic system allowed managers to see at a glance who had accessed supervision and

whether this was managerial or clinical. As most staff had the same person for managerial and

clinical supervision this was usually done as a joint session. However, staff were able to request a

person from outside of their own team for clinical supervision if they preferred, staff were aware of

this but all were happy to have supervision with the person who carried out managerial

supervision.

Staff knew how to report adverse incidents and received feedback on learning from incidents.

Learning was communicated to staff in team meetings and in governance meetings so that

learning could be shared and feedback received. The senior team members of all community

teams attended the governance meetings and therefore learning from other teams could be

cascaded through this meeting.

Team managers had sufficient authority to manage their teams and were well supported by senior

management. There was a commitment to personal development. Staff had accessed specialised

training and managers had access to leadership training.


Team managers were able to add items directly to the trust risk register. They were also aware of

how to escalate a concern through the line management and governance structure if this was

required. Risks were discussed at locality and service level governance meetings.

The building manager was responsible for ensuring that health and safety checks were carried out

as well as managing the risk to the building. This included fire safety checks, legionella checks

and weekly monitoring of emergency alarms. The service had a business continuity plan. This

provided guidance for staff in the event of scenarios such as a building service failure, infectious

disease outbreak, loss of staff or premises, and technological failure



Staff had access to the equipment and information they required to do their job. Care records were

captured on an electronic system available to all staff. The service submitted notifications to

outside agencies as required.

Engagement

There was a trust intranet which provided staff with the latest news from around the trust and a

central system which contained policies and procedures. The trust also had a public facing

website which provided staff, patients, carers and members of the public with information on the

trust.

The service gathered feedback from patients and carers via exit questionnaires sent out on

discharge from the service. The team managers collated this evidence and provided feedback to

patients and carers if they chose to leave their contact details. On an annual basis, the team

managers collated the feedback they had received and used this to pick out themes and trends

that were emerging from feedback, this was presented to the team during meetings.



There were no accreditations for this core service. However, the teams had begun looking into accreditation schemes relevant to their service and were using the benchmarking criteria to improve the work they do.

Student nurses as well as students from other disciplines did placements at the service. Feedback

received from them was positive and students reported enjoying their placements with the team. .

Staff completed mentorship training or associate mentor training in order to support student nurses

and keep up to date with the current curriculum. Staff gave positive feedback about having student

nurses and felt they were a valuable part of the team.


Mental health crisis services and health-based places of safety



female, mixed)

The Longley Centre 136 Suite / Maple

Ward N/A Mixed

Fulwood House Liaison and

Diversion Service

Not clinic based.

Responds to what’s

presented via court/police

etc.

Mixed

Fulwood House

Liaison

Psychiatry

Service

16 Mixed

Fulwood House Out of Hours N/A N/A

Fulwood House Single Point of

Access

Crisis (unplanned)

assessments only N/A

Fulwood House Central AMHP

Team MHA assessments only N/A

Under our methodology for inspecting community services, we inspect a third of all sites registered under NHS trusts. There were six services registered under Sheffield Health and Social Care NHS Foundation Trust’s Crisis and health based place of safety so we inspected two sites covering three teams. These were the single point of access and emotional wellbeing team, the out of hour’s team both based at Netherthorpe House and the health based place of safety at the Longley Centre. The trust has one health based place of safety.

Sheffield Health and Social Care NHS Foundation Trust provide a crisis and out of hours service to people living in Sheffield. The single point of access dovetails with the out of hours service, creating a single point of referral 24 hours a day, seven days a week to people who are between 18 and 65 years of age and who are registered with a GP practice in the city of Sheffield.

The single point of access and emotional wellbeing team carried out triage, crisis assessment, routine assessments and brief interventions. Staff are co-located with out of hours staff and the citywide approved mental health practitioner service and work closely with the home treatment service and liaison psychiatry service.

Referrals are accepted from GPs or other clinical teams within Sheffield Health & Social Care NHS Foundation Trust. Referrals could also be accepted from other health or social care professionals, housing, voluntary sector, relatives and by self-referral. This inspection was unannounced, which meant that staff did not know we were coming to inspect the service. However, before the inspection visit, we reviewed information that we held about the services. We last undertook a comprehensive inspection of the crisis and health based place of safety in November 2016. At that inspection, we rated the services overall as requires improvement. We rated the key questions safe and well led as requires improvement and effective, caring and responsive as good.




Staff did regular risk assessments of the environment. Assessments were in place for both

premises; these were comprehensive and covered all areas.

Interview rooms at Netherthorpe House did not have alarms. However, staff were provided with

personal alarms to take into interview rooms. Staff in the main office were able to respond to

alarms and assessments were done in pairs if risks were high. There were no clinic rooms.

All areas were clean, tidy, and well maintained. Cleaning staff worked daily and cleaning

schedules were in place. The waiting room was small but well maintained with drinking water

facilities.

Staff adhered to infection control procedures. Hand sanitising gel was available throughout the

building and there were washing facilities available. Equipment was well maintained and clean.

The service ensured security processes were followed at all times. All visitors to the services were

required to sign in and out and provide personal identification. However, the door at Netherthorpe

House, which led from reception to the clinic rooms, was faulty and so did not always close. The

manager had reported this to estates.

The health-based place of safety was on Maple ward at the Longley Centre. There was access to

the ward but this was managed by staff. The health-based place of safety met the national

standard. Alarm systems were in place. The room had adequate lighting; there was a bed, a

television, access to food and drinks and a toilet and ensuite shower.

Safe staffing

Definition





Total number of substantive staff leavers 1 February 2017 – 31 January 2018

1.8 N/A

Average WTE* leavers over 12 months (%) February 2017 – 31 January 2018

2% 13%


Total vacancies overall (excluding seconded staff) At 31 March 2018 9 N/A

Total vacancies overall (%) At 31 March 2018 9% N/A


7% 5%

1 February 2017–31 January 2018

4% 5%







Qualified nurse vacancy rate At 31 March 2018 8% -

Nursing assistant vacancy rate At 31 March 2018 25% -

Bank and agency Use


(Qualified nurses) 1 March 2017- 28



(Qualified Nurses) 1 March 2017- 28

February 2018 0 N/A


absence or vacancies (Qualified Nurses) 1 March 2017- 28

February 2018 9 N/A


(Nursing Assistants) 1 March 2017- 28



(Nursing Assistants) 1 March 2017- 28

February 2018 0 N/A


absence or vacancies (Nursing Assistants) 1 March 2017- 28

February 2018 3 N/A


This core service reported an overall vacancy rate of 8% for registered nurses at 31 March 2018. The vacancy rate for registered nurses within this service was above the trust average for 11 of the 12 months. Between April 2017 and March 2018, the vacancy rate reduced from 23% to 8%; although the lowest rate was in August 2017 at 3%.

The vacancy rate for registered nurses was lower than the 16.6% reported at the last inspection.

This core service reported an overall vacancy rate of 25% for registered nursing assistants at 31 March 2018. Between April 2017 and March 2018, the vacancy rate reduced from 56% to 25%; for all months, this was above the trust average, which lay between 1% and 8%.


This core service has reported a vacancy rate for all staff of 9% as of 31 March 2018; the trust does not have a target vacancy rate. This is lower than the rate of 15.5% reported at the last inspection (as of 31 July 2016). Between April 2017 and March 2018, the vacancy rate reduced from 28% to 9%; for all months, this was above the trust average, which lay between 3% and 5%.


Team

Vacan

cies

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Out of Hours

Service

2 15 13% 0 0 - 2 15 13%

Liaison

Psychiatry

1 25 4% 2 7 29% 5 41 12%

Liaison &

Diversion

1 5 20% 0 2 0% 1 9 11%



Service

SPA/Emotio

nal

Wellbeing

1 19 5% 1 3 33% 1 38 3%

Core

service total

5 64 8% 3 12 25% 9 103 9%

Trust total 32 433 7% 15 353 4% 68 1339 5%


Between 1 March 2017 and 28 February 2018, bank staff filled 61 shifts to cover sickness, absence, or vacancy for qualified nurses.

In the same period, no shifts for qualified nurses were covered by agency staff. Nine shifts were unable to be filled by either bank or agency staff.

Team Available shifts Shifts filled by bank

staff

Shifts filled by

agency staff



Liaison

Psychiatry

Service

825 44 (5%) 0 (0%) 7 (<1%)

Out of Hours -* 17 0 2

Core service

total 825 61 0 9

Trust Total 32394

4977

(15%)

1629

(5%)

900

(3%)

*The Trust did not provide total shift data for this team so percentages cannot be calculated

Between 1 March 2017 and 28 February 2018, 16 shifts were filled by bank staff to cover sickness, absence, or vacancy for nursing assistants.

In the same time, no shifts for nursing assistants were covered by agency staff. Three shifts were unable to be filled by either bank or agency staff.


staff

Shifts filled by

agency staff


or agency staff

Liaison

Psychiatry

Service

238 0 (0%) 0 (0%) 0 (0%)

Out of Hours -* 16 0 3

Core service

total

238 16 0 3

Trust Total 59514 21770 (37%) 5623 (9%) 1760 (3%)

*The Trust did not provide total shift data for this team so percentages cannot be calculated

Team Substantive staff


Liaison Psychiatry 38.2 1.8 5%


Liaison & Diversion Service 8.0 0 0%

Out of Hours Service 12.9 0 0%

SPA/Emotional Wellbeing 31.4 0 0%


Trust Total 1351.6 129.6 8%

The sickness rate for this core service was 4% between 1 February 2017 and 31 January 2018.

This was lower than the sickness rate of 8% reported at the last inspection as of 31 July 2016.

Team Total % staff sickness

(at latest month)

Ave % permanent staff

sickness (over the past year)

SPA/Emotional Wellbeing 10% 8%

Liaison & Diversion Service 14% 5%

Liaison Psychiatry 5% 3%

Out of Hours Service 0% 2%


Trust Total 8% 7%

The trust felt that staffing numbers had not been calculated correctly during the reconfiguration.

Senior managers were currently addressing this by reviewing the service. Staff were struggling to

deal with the volume of calls to the crisis service. The service was unable to monitor the volume of

calls and so it was unclear how many people had not been able to access the service. The single

point of access/emotional well-being team had been operational since January 2018. The staff

worked across the two teams on a rotation basis. Staff in the single point of access took crisis calls

and carried out triage and emergency assessments. Staff in emotional well-being carried out

routine assessments and offered brief interventions. There was not enough administrative

resource to support the team and the volume of referrals. The admin team were going through a

reconfiguration so that the support to the team could be increased.

Managers assessed the size of caseloads and staff carried a maximum of 20 patients. However,

staff reported that they were often asked to assist the single point of access to deal with the

volume of calls. There were issues with staff sickness and people leaving the team due to work

related stress. Some staff felt that the role was not what the trust had described during the

reconfiguration. During the reporting period, staffing figures show low vacancy and sickness, rates.

However, the figures are taken from before the reconfiguration. The manager confirmed that there

were two full time nurses on long term sick. Two admin staff were on sick leave and there were

two agency social workers.


The out of hour’s team was fully staffed and any sickness was managed with staff working extra

shifts if required. The team took over the crisis function after 5pm and carried out the single point

of access function from 5pm until 8 am. Street triage workers were also part of this team.

Staffing the health-based place of safety led to capacity issues on Maple ward. The health based

place of safety was part of Maple ward. A band five nurse was available on each shift to cover the

health based place of safety. However, the health based place of safety was receiving a high

number of people detained under section 136 of the Mental Health Act.

A full time psychiatrist and two locums were based at Netherthorpe House, which gave patients

access to medical appointments. The out of hour’s service could access the on call consultant.

Mandatory training

The compliance for mandatory and statutory training courses at 28 February 2018 was 87%. Of the training courses listed, six failed to achieve the trust target and all six failed to score above 75%.

At a team level the Liaison Diversion Service (97%), Liaison Psychiatry Service (92%) and Out of Hours team (88%) all met the Trust Target. The Single Point of Access/Emotional Wellbeing Service completion rate was below the trust target of 80% at 76%. The manager at the single point of access and emotional well-being service thought there were some inaccuracies in the data. They believed that more staff had completed training and this was being addressed. Staff had not received immediate life support training, however the service were not administrating any medication and the service did not have a clinic room. Staff from Maple ward had received training as they worked in the health based place of safety.

This training data is reported based on compliance at the last day of the month, on a month-by-month basis. The training compliance reported for this core service during this inspection was higher than the 74% for the previous 12 months.

Key:



Training course This core service







Falls) 94% 80% 97%















Training course This core service









Staff did a risk assessment for every patient. These were completed during initial triage and

updated with any incidents or contacts with the service. We reviewed 20 patient records. We found

that all records contained a current risk assessment.

The trust used a national risk assessment tool, which was comprehensive and fit for purpose. The

detailed Risk Assessment and Management plan recorded each patient’s history and included

templates for making referrals to GPs and other health professionals. The tool included the

patient’s risk to themselves and others, details of any self-neglect, risk of exploitation and risks to

dependants as well as others.

All service users had a triage completed by the single point of access team. This included a

summary of their presentation and current risks as part of the initial action plan. The triage

document pulled information together in an easily accessible format. However, some staff felt that

they were not given enough time to fully understand the triage information before completing an

assessment. There had been a significant increase in referrals to the team and a new system had

been introduced which meant that routine assessment appointments were offered each morning at

9.30 and 11.00. There were high rates of people not attending for appointments and the trust had

introduced a double-booking system. Staff felt that this was unsafe as if both patients attended

then one would be allocated to another team member. This meant that staff could be assessing a

patient they knew very little about. Managers were available each morning to help staff prepare

for assessments.

Staff carried out an initial triage for all new referrals. Any emergency referrals were offered an

assessment within four hours and any routine assessments were allocated to the emotional well-

being service. Referrals were passed to the team through a dedicated mailbox, this was checked

daily. The out of hours service took over the crisis calls from 5pm and carried out triage and

assessments either over the phone or face-to-face. The out of hour’s service staff updated any

existing risk assessments or created new ones if required.

Joint risk assessments were carried out between the police and nursing staff at the health based

place of safety. The police would stay if risks were deemed significant. A standard operating

procedure had been introduced to ensure that everyone admitted had physical health observations

recorded. A safety checklist of all the actions that must happen when a person was admitted was

in place. The last inspection identified a number of issues in the recoding of patients detained at

the health based place of safety and improvements had been made.


Staff were responding promptly to deterioration in patients’ health and were triaging and assessing

urgent referrals within four hours. However, there were currently 400 people on a waiting list at


Netherthorpe House. The waiting list had been inherited from the reconfiguration when the teams

reduced from four to one. There were 1000 people on the list when the team became operational

in January 2018. Patients had been triaged and sent letters to tell them they were on the waiting

list and given phone numbers of services to contact if in further crisis. Multi-disciplinary meetings

were taking place weekly to review the waiting list. If there had been no further contact then the

referral was closed and a letter sent to the patient. The service worked closely with GPs who were

also sent letters to say if a patient had been closed.

There was a significant delay in patients receiving a timely Mental Health Act assessment. At the

time of the inspection there were 13 people awaiting a Mental Health Act assessment. One patient

had been waiting 10 days. We reviewed five of these records. In one record, a mental health

assessment had been attempted. In one record, the recovery team had recorded that the patient

had refused medication but that no further attempt to contact the patient had been made. The

reasons for delay in assessment were documented as a lack of available beds, lack of police

support and approved mental health practitioner availability. The trust did not use out of area

mental health beds. We reviewed incidents at Netherthorpe House from March – June 2018 and

found that out of 26 incidents 16 related to a delay in a Mental Health Act assessment. Managers

were aware of the issues and these were contained within the risk register. Bed managers were

making decisions about the priority for assessments and there was support from managers within

the team. The approved mental health practitioner team had been centralised as part of the

reconfiguration. The team were located at Netherthorpe House. Daily meeting took place to review

patients on this list. However, there was a disconnect between what staff and managers were

saying. Senior managers felt that the risks were being appropriately managed but staff felt that the

process was very unsafe.

Patients brought into the health place base of safety were managed on an individual basis. The

police would stay if the risks were deemed high. There had been four incidents’ during May 2018

where the health based place of safety had been closed to accommodate a patient admitted on to

the ward. A protocol was in place which clearly stated what staff must do if this occurred. The

protocol ensured that senior managers and the police were involved in the decision to close the

health based place of safety.

Lone working procedures and policies were in place. Staff would carry out assessments in pairs if

risks had been identified. The out of hour’s team would arrange any face-to-face assessments

when the night shift staff arrived so that staff were not working alone.

Safeguarding

A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include physical, emotional, financial, sexual, neglect and institutional.

Each authority has their own guidelines as to how to investigate and progress a safeguarding referral. Generally, if a concern is raised regarding a child or vulnerable adult, the organisation will work to ensure the safety of the person and an assessment of the concerns will be conducted to determine whether an external referral to Children’s Services, Adult Services or the police should take place.

This core service made no safeguarding referrals between 1 February 2017 and 31 January 2018. However, this data was taken from before the reconfiguration. We requested further data and found that the service made five referrals between 1 February 2018 and 31 July 2018. Any safeguarding concerns were discussed with the Safeguarding Manager within the trust. This


process was in place to provide oversight of the safeguarding process and outcomes of any concerns.

Staff were up to date with safeguarding level one training for adults and children. Some staff were waiting to access level two. They knew and understood their responsibilities around safeguarding.

Staff could give examples of how to protect patients and could identify possible reasons why adults and children could be at risk.



The trust used an electronic patient record system. The system was easy to use and patient

records could easily be found. The system was used across all trust services so patient’s records

could be shared across different teams.

Staff at the health-based place of safety had a new tablet to use during assessments. This meant

that they had access to a patient’s record while off the ward and could update records.


Medication was managed through agreement with a patient’s own GP. Psychiatrists prescribed medication and this was managed locally with GPs and pharmacist. There were good working relationships between the two.



Between 1 March 2017 and 28 February 2017 there was one STEIS incidents reported by this

core service. This incident was categorised as an ‘Apparent/actual/suspected homicide’.


We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was comparable with STEIS.

The number of serious incidents reported during this inspection was similar to the two reported at the last inspection between April 2015 and March 2016.


Type of incident reported on STEIS Liaison Psychiatry Total

Apparent/actual/suspected homicide 1 1

Total 1 1





The trust had an electronic system to report incidents. Staff could describe how to complete an incident form. We reviewed 12 incidents at the health-based place of safety and found that these had been investigated and findings were shared with staff. Changes were been made to the environment at the health based place of safety in response to incidents. We saw that staff had been debriefed after a serious violent incident. Relationships with the police had also improved after the incident was discussed at the joint liaison meeting where lessons were shared and learnt.

We reviewed 26 incidents at Netherthorpe House and found that these were also investigated. We saw that where there were recurring issues such as problems with the telephone system these had been placed on the risk register.

Staff had the option for incidents to be sent to other relevant people within the trust. This could include senior managers or safeguarding leads. Incidents were monitored through the trust governance meetings.




Staff completed a comprehensive mental health assessment of each patient. We looked at 10

patient records at Netherthorpe House and found that all had received a full mental health

assessment.

Staff had close links with GPs and were aware of medications and health issues. The service did

not have the facilities to carry out physical healthcare checks.

Staff described how they were working with patients to identify their needs. Patients were offered

three sessions, which covered an assessment and two brief interventions. However, none of the

records reviewed contained a written care plan.

Staff did not always know the patients background and full risk assessment when completing an

assessment. The service had introduced a new system for booking appointments, which meant

that staff did not always have time to read patients notes. Managers had offered to help with this

by pulling together a summary for each patient due to be seen that day.

We observed three assessments where staff had to apologise for not knowing the patients full

background. Staff expressed frustration on the system, which they often found unsafe.

In the 10 records reviewed at the health-based place of safety, we found that patients were being

assessed and were receiving physical health checks. However, there were some incomplete 136

records where physical health and observations had not been recorded. Managers were

monitoring issues through a monthly audit of the records. Managers had introduced new

processes to ensure that staff were recording correctly. The team had made significant progress in

terms of recording since the last inspection.

There had been 165 detentions into the health-based place of safety in the last six months.

December 2017 20

January 2018 17

February 2018 23

March 2018 42

April 2018 21

May 2018 42

It was acknowledged that this number was high and that the reasons were not fully understood.

The trust was investigating this since it was expected street triage should reduce the number of

detentions. There had been a total of 504 street triages in the previous six months. Police officers

were now calling ahead to the health-based place of safety to discuss patients and where possible

were utilising street triage.


Patients were having an assessment of their needs and interventions were being delivered Staff

were providing crisis interventions that involved an assessment and two brief interventions.

Patients had access to medication through the consultant who worked closely with GPs. Patients


had access to psychological therapies. The service worked closely with GPs to ensure that

patient’s physical health needs were being met. However, staff felt that three appointments limited

the work they could do with patients. Services in the community had reduced so signposting was

not always an option. We were given an example of where the recovery team had declined a

referral, as the patient was not ready for recovery. The worker then had nowhere to refer the

patient for extra support. Housing and employment issues were being discussed and support

offered from the teams support worker. However, this was one post and staff felt that they could

not always cover all aspects of housing and employment during three sessions.

Monthly audits were being carried out at the health based place of safety. These assisted the

manager to deal with any issues in terms of recording. However, staff at Netherthorpe House were

not participating in benchmarking and quality improvement.

This core service participated in the following clinical audits as of their clinical audit programme in

the 12 months leading up to the submission of the provider information return.


completed


audit

Collaboration

with Primary

Care Clinicians

Service users

on CPA

Provider









solution.

Record keeping


Provider




staff on use of



relevant policy.

Audit of risk

assessments

2016/2017

Trust wide Provider







in 2017/18.

Audit of risk

assessments

2017/2018

Trust wide Provider


Audits of care

plans Trust wide

Provider

wide Clinical audit

January

2018


small scale audits.


teams.

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG43

Transition from

children’s to

adults’ services

Trust wide Provider


Findings fed into






transitions


for young

people using

health or social

care services

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG13

Workplace

health:

management

practices

Trust wide Provider

wide Clinical audit

September

2017



future

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG58

Coexisting

severe mental

illness and

substance

misuse:

community

health and

social care

services

Trust wide Provider

wide Clinical audit

December

2017

Action plan under

development


All services had a full range of specialists within the teams including psychiatrists, psychologists,

nursing staff, support workers, occupational therapists, and social workers.

Staff were experienced, qualified and had the necessary skills to deliver effective care and

treatment to meet the needs of their patients. Staff had completed mandatory training although

there were capacity issues at Netherthorpe House where staff felt that they were unable to access

specialist training for their individual role. Staff had been given an induction into the new team but

felt that this did not reflect the roles they were now doing.

Managers provided staff with supervision and appraisals. The trust’s target rate for appraisal

compliance is 90%. As at 31 January 2018, the overall appraisal rates for non-medical staff within

this core service was 98%.



Team name

Total number of


staff requiring an

appraisal

Total number of

permanent non-

medical staff who


% appraisals

Liaison Psychiatry 36 36 100%

Out of Hours Service 15 15 100%


Team name

Total number of


staff requiring an

appraisal

Total number of

permanent non-

medical staff who


% appraisals

SPA/Emotional Wellbeing 33 34 97%

Liaison & Diversion Service 7 8 88%


Trust wide 1440 1495 96%

The trust’s target rate for appraisal compliance is 90%. As at 31 January 2018, the overall


No data for the rate of appraisal compliance for medical staff was reported at the last inspection.

Team name

Total number of



Total number of

permanent medical

staff who have had

an appraisal

%

appraisals





The trust’s measure of clinical supervision data is sessions delivered with a target of 66%.

Between 1 March 2017 and 28 February 2018 the average rate for non-medical staff across all four teams in this core service was 94%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.

The rate of clinical supervision reported during this inspection was higher than the 60% reported at


Team name Clinical supervision

sessions required

Clinical

supervision

delivered

Clinical

supervision rate

(%)

Liaison & Diversion Service 48 48 100%



Out of Hours Service 135 107 79%



Between 1 March 2017 and 28 February 2018 the rate for medical staff in this core service was 25%, all staff were within the Liaison Psychiatry team.



Team name


sessions required

Clinical

supervision

delivered

Clinical

supervision rate

(%)





Multidisciplinary team meetings at Netherthorpe House were well attended but their effectiveness

was limited. Netherthorpe House held multidisciplinary meetings every Tuesday and Thursday

morning. There was no clear focus. Some patients discussed had not been seen by the staff

discussing them. Staff were often unable to attend multidisciplinary meetings due to the

introduction of new assessment times. However, there was close working with the Home

Treatment Team and joint assessments were available to patients. The out of hour’s team started

at 4pm to allow for a handover period from the single point of access.

Staff at the health based place of safety worked closely with the police, approved mental health

practitioner service, and ambulance service. Joint police liaison meetings took place and were well

attended by all agencies. Relationships were improving with the police who were now calling the

ward to discuss a patient before bringing them to the health-based place of safety.

Joint liaison meetings took place each quarter. The aim of the group was to ensure good

coordination and dialogue between statutory agencies who share functions and responsibilities

under the Mental Health Act 1983. The group was well attended and included representatives from

all agencies including the police, ambulance, local authority, acute hospital, and the trust.

Discussions took place around the health based place of safety, street triage and incidents on

inpatient wards requiring police attendance.

The trust was working closely with South Yorkshire police around training on knowledge and skills

when dealing with a mental health issue. The training had allowed both trust staff and police

officers the opportunity to learn about each other roles and responsibilities.

Figures showed that December 2017 – May 2018 165 people had been detained under section

136 of the Mental Health Act, in the health based place of safety. The service felt that this was

high and discussions had started take place to identify possible reasons.


Practice

As of 28 February 2018, 67% (two out of the three) of the eligible workforce had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years.


Staff had a good understanding of the Mental Health Act. Care and treatment was discussed with patients. Staff had access to administrative support and legal advice on the implementation of the


Mental Health Act and its code of practice. Staff knew who their Mental Health Act administrators were. Policies and procedures were available.

However, the trust was not managing Mental Health Act assessments. Anyone identified as needing a Mental Health Act assessment was referred to the service at Netherthorpe House. At the time of the inspection, the trust had 13 people awaiting a Mental Health Act assessment. Bed managers monitored the list daily and senior managers were available for support.

Patients detained at the health-based place of safety had their rights explained to them and this was audited monthly. Patients had access to independent mental health advocacy services.

The health-based place of safety safely stored detention paperwork, consent to treatment forms, approved mental health professional reports, and second opinion approved doctor reports. Copies of Mental Health Act documentation were scanned onto the electronic patient care record, which meant all staff could access them when needed.


As of 28 February 2018, 95% of the eligible workforce had received Level 1 Mental Capacity Act

training and 91% of those eligible had received Level 2 training. The trust stated that this training

is mandatory for all core services for inpatient and all community staff and renewed every three

years.

The training compliance reported during this inspection was higher than the 22% (Level 1) and 0% (Level 2) reported at the last inspection.

Relevant policies and procedures reflected recent guidance and staff had access to these on the intranet.

Staff understood and could explain the five principles of the Mental Capacity Act. Staff could give examples of when they would need to assess someone’s capacity. The team would assume capacity unless anything suggested otherwise. Staff supported patients to make decisions about their care and treatment and other decisions affecting their lives.




Staff attitudes and behaviours towards patients were discreet, respectful, and responsive. We

observed staff being flexible in terms of home visit appointment times. We observed three

assessments at Netherthorpe House and found the staff to be caring and respectful towards

patients. However, due to the appointment system we saw that a patient had to wait in the waiting

room for up to 30 minutes after their appointment time.

The staff rooms were busy and noisy and faced a main road. The volume of calls meant that

several conversations could be happening at the same time. Staff sometimes found it hard to hear

what patients were saying and had difficulty concentrating in the open plan office.

Staff were attempting to signpost patients to community and other trust services. However, due to

the introduction of three sessions patients were often not ready to be referred. The three sessions

involved an assessment and two brief interventions. Staff were aware of services in the

community and where possible were making referrals.

We spoke with seven patients who all said that staff treated them well and behaved appropriately

towards them.

The patients we spoke with at the health-based place of safety said that staff were kind to them

but they did not always understand why they were there. The patients we spoke with had been

detained under the Mental Health Act and were now on Maple ward. It was difficult to interview

these patients since they were unwell at the time. We were unable to speak to any patients who

had used the health-based place of safety and were now back in the community.

Involvement in care


We reviewed 10 patient records at the Netherthorpe service and found that none of these

contained a care plan. However, we saw that patients were involved in assessments and in

planning their care. Patients were given an information leaflet when they accessed the service and

could give feedback through the friends and family test.

Patients who had accessed the health based place of safety were given feedback forms to

complete and results were mainly positive. However, there was low uptake and the service was

considering attempting to gain feedback after the patients had left and were more able to reflect on

their experience.

Patients had access to advocacy and we saw in records that patients had accessed this.


Staff involved and informed families where possible. We spoke with three carers who spoke highly

of the service. They felt involved in discussions about treatment. Where patients gave consent,

families were involved in assessments and in discussions around treatment options. Families

would often call the crisis number either during the day or out of hours if they were concerned

about a loved one.


Carers were given information on how to access carers assessments and also support for

themselves.

Families were able to give feedback as part of the friends and family test.




The service had a set target for time from referral to triage/assessment. The clinical

commissioning group had set the target. All urgent referrals had to be assessed within four hours

and non-urgent referrals within three weeks. The service was meeting the target for urgent

referrals but patients were currently waiting seven to nine weeks for a routine assessment.

The telephone line was not fit for purpose. The service was unable to monitor the volume of calls and how long people had been waiting. This had been identified and escalated through the mobilisation meetings. The management team had investigated the issue which was on the risk register. The trust had put mitigation in place which included the recruitment of an additional two dedicated telephony staff. The existing telephony system had been improved to include a series of line management escalatory call groups. This meant that calls unanswered within eight rings would be escalated. An answer phone facility had also been added to the telephone line. However, staff reported not to have enough capacity to review the answerphone during the day. The trust had plans to pilot a new telephone system and this was being driven at a senior level.

The single point of access had a waiting list of approximately 400 patients. The team had come

together in January 2018 and had inherited the list from the reconfiguration. Everyone on the list

had been triaged and sent a letter to say that they were currently on a waiting list. The letter

contained numbers to call if in further crisis.

The team consisting of psychiatrist, senior practitioners and managers, worked together to review

the waiting list weekly and any patient who had not made contact in the last year was removed

from the list. Patients and their GP were sent a letter informing them of this decision. The clinical

commissioning group were monitoring the trust on the waiting list and regular performance

meetings were taking place.

The team took active steps to make contact with patients that did not arrive for their appointment

by phoning them to check their wellbeing and informed patient GPs. If they did not attend after

three appointment times, they were removed from the service waiting list.

Appointment times for routine assessments were not flexible to reflect patient choice. They were

held every morning at 9.30 and 11am. There were high do not attend rates for assessments and

the trust had introduced a double booking system. We observed a situation where both patients

arrived for the appointment and so one had to wait to be seen.

The trust were recording the length of time people were waiting for an assessment in the health

based place of safety. Of the people accessed in the health-based place of safety, 53 were

assessed within two hours, 94 between two and 16 hours, and five between 16 and 24 hours. One

patient waited over 24 hours. Guidance introduced in December 2017 reduced the time someone

could be detained under section 136 from 72 hours to 24 hours with the possibility of a further 12-

hour extension in specific circumstances.


Both services had a range of rooms to support treatment and care. However, some of the

interview rooms at Netherthorpe House did not promote comfort, dignity, and privacy. Some of the

interview rooms faced a noisy main road. The noise from the main road made it difficult to hear

during assessments. The main office was also very busy which meant that staff could not always

hear a patient on the telephone. There were often several conversations happening at the same

time with people typing notes in the background.


The health-based place of safety met the national standard. This consisted of two bedrooms and

an assessment room. Patients had access to food and drink and a clock was visible.


Where possible staff supported patients with issues around housing and employment. The

assessment process identified these issues. A support worker picked up these issues, however,

this was one post for the whole team, and staff felt that they did not have the time to effectively

deal with all issues. Social work assessments were taking place to identify any social needs and

there was access to social care funding.

Community resources such as support groups were available. However, some were no longer

taking referrals due to capacity.

Patients were encouraged to maintain relationship with family and friends and where possible

families were given information on support agencies.

There were good links with the police and the street triage was working with people in their own

communities.


The service at Netherthorpe House had disabled access and patients could be seen in the community or their own homes if required. Information leaflets were available in different languages and formats and the service had access to interpreters.

The out of hours and street triage had identified core hours for activity and had shaped staffing around this. The team had been looking at response times to phone calls with the use of the answering machine, staff from the out of hours team had the capacity to do this.

Information leaflets were available in other languages and the staff had access to interpreters and signers.


Patients knew how to complain or raise concerns. There was information available to patients on

how to make a complaint and they were supported to do this. The core service had only received

one complaint between 1 March 2017 and 28 February 2018, which was not upheld. It was not

clear if patients who had been unable to access the service were made aware of their right to

complain.

The number of either partially or fully upheld complaints reported during this was lower than the one reported at the last inspection.

Team name Total

Complaints

Fully

upheld

Partially

upheld

Not

upheld

Referred to

Ombudsman

Upheld by

Ombudsman

Liaison

Psychiatry

Service

1 0 0 -

This core service received three compliments during the last 12 months from 1 March 2017 to 28

February 2018, which accounted for less than 1% of all compliments received by the trust.



Leadership

Leaders had the skills, knowledge, and experience to perform their roles. The operations manager

at Netherthorpe House understood the challenges faced by staff. The team was new and the

manager was aware of the issues with waiting lists, telephone line and staff morale. Leaders were

visible in the service. However, staff at Netherthorpe House did not feel supported by senior

leaders.

Staff felt that the trust had underestimated the capacity of the service, which had resulted in a

substantial waiting list. Staff felt that systems were introduced that did not meet the needs of the

service. Staff had raised concerns about the introduction of the new assessment appointment

times and felt that they were not heard. Staff morale was generally low.

However, senior managers were aware of the issues at Netherthorpe and had plans in place to

improve the service. Weekly mobilisation meetings were taking place and there were plans to

relocate the service. Senior managers held weekly sessions with staff and were visible at the site.

The manager at Maple ward managed the health-based place of safety and could demonstrate

good leadership. The trust had acknowledged the staffing issues and measures had been put in

place to recruit more staff.

Vision and strategy

Staff knew and understood the trusts vision to improve the mental, physical, and social wellbeing of the people in communities. The values of respect, compassion, partnership, accountability, fairness, and ambition were applied to daily work. However, staff did not feel that the trust had successfully communicated the vision for the new service and that their daily work did not reflect the service they thought they would be delivering. The trust had a vision for a crisis hub, which would locate the crisis, and health based place of safety together. A working group had responsibility for ensuring these developments were in place for the autumn 2018.

Culture

Staff felt respected, supported, and valued by managers at a local level. However, they did not feel respected or valued by the wider trust. This was mainly due to fact that they perceived the trust had poorly handled the reconfiguration of the service. Staff did not feel positive about the service they were offering and felt that at times it was unsafe. Staff felt able to raise concerns but felt that these concerns were not always listened to.

Staff knew how to use the trust’s whistleblowing procedures and could access them via the trust’s website. Staff also knew whom the trust’s freedom to speak up guardian was and what their role was in respect of supporting staff to speak out and raise concerns. We spoke with the service leads who confirmed staff had approached the guardian about their concerns over the reconfiguration exercise.

The trust had a performance management system in place, which included procedures for managers who needed to address poor staff performance. Staff confirmed that the manager supported them if there were ever difficulties within their team.

The trust promoted equality and diversity in its day-to-day work and in providing career progression. The trust had equality and diversity policies in place, which were available to all staff


via the trust’s intranet. Discussions during staff supervision and appraisals focussed on issues around equality and diversity.

There was some sickness within the team at Netherthorpe House and some use of agency for social workers.

Staff had access to support for their own physical and emotional health needs. This included support from the trust’s workplace health and wellbeing group, smoking cessation support, and an occupational health service.

During the reporting period, there were zero cases where staff have been either suspended, placed under supervision, or were moved to a different team within this service.

The number of staff placed under supervision, suspended or moved team during this inspection was similar than those reported at the last inspection (1 suspended) between 18 September 2014 and 27 September 2016. Please note, this may not be comparable depending on the type of restriction detailed at the previous inspection.


Governance

Staff received regular appraisals and supervision. Staff knew how to report incidents, handle

complaints and used lessons learned from investigating incidents and complaints to improve

practice.

Staff understood arrangements for working with other teams, both within the provider and

externally, to meet the needs of the patients. However, staff at the Netherthorpe House said

opportunities to signpost had decreased due to capacity within the voluntary sector. Staff worked

with colleagues within the trust’s recovery and home treatment teams and shared information

through electronic systems, face-to-face meetings, and e-mail. Staff knew how to identify possible

signs of abuse, how to make a safeguarding alert and did so when appropriate.

Staff had a good understanding of the Mental Health Act and Mental Capacity Act and a central

team within the trust monitored staff compliance with the acts and provided advice and guidance

to staff when required.

We spoke with seven people who used the service and their feedback was positive. They said

staff were kind, caring and respectful, involved patients and carers in decisions about their care

and treatment gave patients and carers opportunities to provide feedback and understood their

individual needs.

The services monitored a range of information including referral sources, waiting times, and

response times. However, there were a significant number of people waiting to access the crisis

service and 13 people waiting for a Mental Health Act assessment. The telephone line was not fit

for purpose and so the service was unable to monitor the numbers of people trying to access the

service.

Staff at Netherthorpe House were not completing audits and this was linked to the volume of work.

The staff at the health based place of safety did monthly audits of the 136 detentions and

associated paperwork. However, the trust did not always record how long a patient had waiting for

an assessment.

Staff understood the need to work closely with other trust services such as the home treatment

team, recovery teams to meet the needs of patients. Where possible joint working took place.


Management of risk, issues, and performance

Staff maintained and had access to risk registers. Staff at Netherthorpe House had escalated

concerns in relation to waiting times, the telephone system and the reconfiguration of admin staff.

Other issues included bed management, and lack of police attendance at Mental Health Act

assessments. All the issues raised by the services were on the risk register. Senior managers

understood the issues and were working on ways to ensure the issues were dealt with. However,

staff working within the centralised approved mental health practitioner team felt that the number

of people awaiting a Mental Health Act assessment was a concern.


The services used the trusts electronic system to record patient information. The system was

effective and easy to use. Staff at the health-based place of safety had access to a tablet so that

they could record patient’s assessments and risk plans whilst in the place of safety. The staff at

Netherthorpe House had a hot desk policy; this could be problematic when having to log off whilst

away from desk. Staff would sometimes come back and have to find another desk and information

could be lost.

Information governance training was a mandatory requirement for staff within the trust. This

training included the need to ensure that all staff maintained patient confidentiality at all times.

Managers did not have all the information they needed on the performance of the service.

Managers were unable to know how many people were unable to access the crisis service. The

service managers used key performance indicators to monitor compliance in relation to mandatory

training and other progress within their teams. However, since the team was new the manager

was still pulling together staffing information from previous teams.

Engagement

Staff, patients, and carers had access to up-to-date information about the services they used and

wider trust through social media, emails, newsletters intranet, and internet. Patients and staff could

meet with members of the senior leadership team and governors to give their feedback and ideas

for shaping the service. Although the staff at Netherthorpe House felt that they were not listened

to, we saw that senior managers did visit the service frequently and were aware of the concerns.

The trust had engaged people who used the service and other stakeholders in the reconfiguration

exercise during feedback sessions, presentations, and drop in sessions. Staff had been involved

in sessions but felt that decisions had already been made.


The reconfiguration was a whole system redesign improvement programme introducing a new way of working. Staff had been engaged in the process through to options appraisal, recommendation and mobilisation. The service model for the single point of access was refined in response to feedback from staff during the engagement and consultation phases. However, some staff felt that the current service did not reflect the service designed during the reconfiguration. Staff were under pressure daily to deal with the volume of calls and assessments. They were doing this alongside work to reduce the waiting list. Staff were not participating in any research.

Innovations were planned with the development of a crisis hub to bring together crisis and health based place of safety. Senior managers gave an overview of developments and these were to be in place by autumn 2018.



The table below shows which services within this core service have been awarded an accreditation together with the relevant dates of accreditation.

Accreditation scheme Service accredited Comments and date of accreditation / review

Psychiatric Liaison Accreditation

Network (PLAN)

Liaison Psychiatry 21st March 2017- 2020


Wards for people with a learning disability or autism



female, mixed)

Assessment & Treatment Service

Service – Firshill Rise

Firshill Rise

Assessment &

Treatment

Service

7 Mixed

Firshill Rise assessment and treatment service is a mental health ward for adults with a learning

disability or autism provided by Sheffield Health and Social Care NHS Foundation Trust. The

service provides care and treatment to male and female patients over the age of 18. The ward can

provide care and treatment for up to seven patients. It has six bedrooms and one self-contained

flat. Patients are admitted to the service because they have severe mental health problems and/or

because they are presenting challenging behavior, which cannot be supported in the community or

in mainstream adult inpatient mental health services.





The service had a part-time buildings manager who undertook environmental risk assessments including health and safety assessments and fire risk assessments. Clinical staff carried out regular risk assessments of the ward areas. Staff took action in response to incidents involving environmental risks. The last ligature risk assessment was completed in October 2017. The trust reported that the ward presented a high level of ligature risk due to the acuity of patients and remaining ligature anchor points in the self-contained flat area, which including taps which were not anti-ligature taps and had handles on cupboard doors. The accessible bedroom also had an overhead hoist.

In areas regarded as high risk, such as patient bedrooms, the trust had installed anti-ligature fittings. The trust had taken the following actions to mitigate ligature risks: risk assessments and observations levels where ligature risks remained; removal of items that may be used as ligatures.

The layout of the ward did not allow staff to observe all parts of the ward; staff mitigated these risks by observing patients at regular frequencies.

The ward was mixed sex. All bedrooms contained en-suite toilet and bathing facilities and female patients had access to a female only lounge. Over the 12-month period from 1 March 2017 to 28 February 2018 there were no mixed sex accommodation breaches within this core service.

Staff carried personal alarms and nurse call points were available in all bedrooms for patients to call for assistance from staff when required.


The ward was clean and had good, well-maintained furnishings. The ward had a cleaning

schedule and dedicated housekeeping staff supervised by the buildings manager. Cleaning

records were up to date and demonstrated that staff cleaned the ward regularly.

Staff had effective processes in place to reduce the risk and spread of infection, including

handwashing, with signage in appropriate areas and antibacterial hand gel dispensers placed in

communal areas and toilets. Staff carried out regular infection control audits and had action plans

in place to maintain standards.

At the last comprehensive inspection in November 2016, patients had access to a clinic room

located away from the ward area. This meant staff stored patient medication in the staff office and

they carried out health checks in patient bedrooms. We were concerned that this could have

increased the risk of infection to patients. However, the trust had created a clinic room on the

ward, which meant staff could store patient medication away from the staff office and could carry

out patient health checks on the ward in a designated room.

For the most recent Patient-led Assessments of the Care Environment (PLACE) assessment

(2017), the location scored higher than the similar trusts for two of the three applicable aspects

overall and similar to other trusts for cleanliness.

The table below shows the Patient-led Assessments of the Care Environments assessment score

for 2017:


provided


appearance

and

maintenance

Dementia

friendly

Disability


Firshill Rise

MH – Wards for

people with learning

disabilities or autism

98.6% 98.2% N/A 91.1%

Trust overall 99% 97.8% 91.1% 91.8%


health and learning

disabilities)

98% 95.2% 84.8% 86.3%

Seclusion room

Since our last inspection, the trust had removed one of the patient bedrooms and built a seclusion

room. Prior to this, the ward did not have seclusion facilities. The seclusion room allowed staff

clear observation of patients and had a two-way communication system in place. Patients in the

seclusion room had access to toilet and washing facilities. The room had air conditioning, which

allowed staff to control the temperature in line with patient need. Patients could see a clock and

the room had natural light. Staff told us that if they secluded patients who could not read the time

from the clock, they encouraged them to ask staff for the time.


The ward had a newly refurbished fully equipped clinic room with an examination couch and

emergency drugs, which staff checked regularly. Staff had access to resuscitation equipment,

which they stored in the staff office. Staff checked and maintained this equipment.

Safe staffing

Nursing staff

Definition






2.8 N/A


11% 13%





14% 5%

Average sickness rate over 12 months 1 February 2017 to 31 January 2018

14% 5%










Bank and agency Use



February 2018 698 (41%) N/A


(Qualified Nurses)

1 March 2017 and 28

February 2018 447 (26%) N/A



1 March 2017 and 28

February 2018 104 (6%) N/A



1 March 2017 and 28

February 2018 3602 (58%) N/A



1 March 2017 and 28

February 2018 665 (11%) N/A



1 March 2017 and 28

February 2018 361 (6%) N/A




This core service reported an overall vacancy rate of 17% for registered nursing assistants.

The vacancy rate for nursing assistants was lower than the 20% reported at the last inspection.

This core service has reported a vacancy rate for all staff of 12% as of 31 March 2018. This was similar to the rate reported at the last inspection (between 1 August 2016 and 31 July 2017).


Ward/Tea

m

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Vacanci

es

Establishm

ent

Vacan

cy rate

(%)

Firshill

Rise

1 7 14% 3 18 17% 4 33 12%

Core

service

total

1 7 14% 3 18 17% 4 33 12%

Trust

total 32 433 7% 15 353 4% 68 1339 5%



In the same period, agency staff covered 26% of shifts for qualified nurses. Six percent of shifts were unable to be filled by either bank or agency staff.


staff

Shifts filled by

agency staff




Firshill Rise 1721 698 (41%) 447 (26%) 104 (6%)

Core service

total

1721 698 (41%) 447 (26%) 104 (6%)

Trust Total 32,394

4977

(15%)

7252

(22%)

900

(3%)



In the same time-period, agency staff covered 11% of shifts. Six percent of shifts were unable to be filled by either bank or agency staff.


staff

Shifts filled by

agency staff


or agency staff

Firshill Rise 6189 3602 (58%) 665 (11%) 361 (6%)

Core service

total 6189 3602 (58%) 665 (11%) 361 (6%)


(37%)

5623

(9%)

1760

(3%)


Senior managers set the minimum daily staffing levels, but the ward manager could adjust these

as needed based on the needs of the ward and patient acuity levels. At the last comprehensive

inspection in November 2016, the staffing level was two registered nurses and three support

workers on duty during the day and one registered nurse and two support workers on duty

overnight. However, managers had increased staffing levels to two registered nurses and five

support workers during the day and one registered nurse and four support workers at night. These

levels were above the minimum staffing levels set out by the trust. Managers of the service had

put in a business case to keep staffing at the current levels on a more permanent basis due to

patient acuity levels.

The ward manager and the deputy could be counted into the staffing numbers and had been

covering shifts to fill registered nurse shifts. The service had recently recruited two new registered

nurses. There was always at least one registered nurse present on the ward and managers could

deploy agency staff or bank staff to cover shortfalls. The service had a high rate of bank staff to

cover shifts but these staff were already employed by the trust and undertook additional work at

the service when needed.

We had concerns that new staff and agency staff appointed to work on the ward did not always

complete an induction before starting work on the ward. Some staff told us they felt unsafe on the

ward because of this. Following our inspection, we asked the service to provide further information

about this. The data they supplied showed that in the three months prior to our inspection,

managers had recruited three new permanent members of staff to work on the ward. Of these, two

staff had not received an induction prior to commencing their first shift. They were mostly up-to-

date with their mandatory training including training in managing aggression but two staff had not

completed clinical risk assessment training, two had not completed Mental Capacity Act level two

training, two had not completed medicines management training and two had not completed rapid

tranquilisation training. None of them had completed their mandatory training in the Mental Health

Act. The data also showed the hospital had appointed three new agency staff and none of them

had completed an induction prior to starting their shifts.


As part of our inspection, we interviewed five staff on duty including a mixture of support workers

and registered nursing staff. Four of the staff we spoke with told us they thought the service was

short of staff, which resulted in them regularly having to cancel patient leave and activities. We

also spoke with three patients as well as the advocacy service who regularly visited patients on

the ward. One patient and the advocacy service told us that the provider cancelled activities

regularly because there were not enough staff to facilitate them. We asked the provider for

information about how many episodes of leave they cancelled because of staff shortages. They

reported that in the three months prior to our inspection, staff had to cancel four episodes of

patient leave due to staff shortages.

Data provided prior to the inspection showed that between 1 March 2017 and 28 February 2018,

the service could not cover six percent of shifts with bank or agency staff. On the day of the

inspection, we could see that two support staff had reported in sick so there were two nurses and

three support workers on duty. Staff told us they may have to cancel activities and patient leave

but the number and grades of staff on duty was still within their minimum safe staffing levels.

Two staff we spoke with told us that a minimum of three staff trained to deliver restraint and

seclusion should be on duty at each shift but that this did not always happen. Between 5 March

2018 and 11 June 2018, there were 13 shifts that fell below the minimum of three RESPECT

trained staff on shift. RESPECT training included training in positive behavioural support and

restraint techniques. This represented 4% of the total shifts during this time period. The service

was a standalone unit, which meant that it did not have any additional support from staff in other

services to restrain and seclude patients where this was necessary.

This core service had 2.8 (11%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 24% reported at the last inspection (between 1 August 2016 and 31 July 2017).



Firshill Rise 24.2 2.8 11%


Trust Total 1351.6 129.6 8%

The sickness rate for this core service was 14% between 1 February 2017 and 31 January 2018.

.


(at latest month)



Firshill Rise 14% 14%


Trust Total 8% 7%

Managers told us their rates of sickness absence were higher than the trust average due to staff

stress and assaults on staff. However, managers had conducted a stress audit and introduced

initiatives to reduce the number of assaults on staff in an attempt to reduce staff absence.



Firshill Rise had a fill rate of over 125% for nurses for all day shifts reported.

Key:

> 125% < 90%

N-Nurses

C- care staff

Medical staff

Between 1 March 2017 and 28 February 2018, no shifts were filled by bank staff to cover


In the same time period, agency staff covered 22 shifts. Zero shifts were unable to be filled by

either bank or agency staff.


staff

Shifts filled by

agency staff


or agency staff

Firshill Rise Not provided 0 22 0

* Percentage of total shift

There was adequate medical cover provided by a psychiatrist and specialty doctor. Staff could

speak with an on-call psychiatrist, for example, at night if they needed to. The service covered

planned and unplanned absences using responsible and approved clinicians from other parts of

the trust, for example, from the community learning disabilities team.

Mandatory training

The compliance for mandatory and statutory training courses at 28 February 2018 was 89%. Of the training courses listed four failed to achieve the trust target and of those, three failed to score above 75%.


Key:




N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

November 2017 December 2017 January 2018 February 2018 Firshill

Rise

188.1 153.4 96.8 243.1 174.5 133.7 100.0 225.4 151.3 118.0 100.0 173.2 148.7 118.7 96.4 176.6










Falls) 100% 80%

97%












Dignity standards) 80% 80%

85%






At the last comprehensive inspection in November 2016, we told the service they should ensure

that staff completed mandatory training for autism awareness, dementia and Deprivation of Liberty

Safeguards. Data provided for this inspection showed that managers provided staff with

mandatory training and most were up-to-date with this. When we spoke with staff, they confirmed

they received mandatory training and we saw that each month, managers reviewed training data

to track staff compliance.

In four mandatory training courses, we saw that staff compliance rates fell below the trust target of

80% and for three courses, compliance rates fell below 75%, the rate that CQC consider the

minimum compliance level. The courses that fell below 75% were adult basic life support,

information governance and the Mental Health Act. However, managers had clearly identified

which staff needed to complete their mandatory training and had booked them onto future course

dates.



All six patients’ care and treatment records we looked at contained a comprehensive risk

assessment using a trust wide tool called the detailed risk assessment and management plan.

Staff carried out risk assessments on admission to the service and updated these regularly.


Staff responded to changes in risk profile by using a clinical progress tracker. At every shift staff

recorded patient behaviours, which they then shared with multi-disciplinary team twice per week

and at handovers. The tracker was colour coded, green for adaptive behaviours, amber for early


signs of unease, and red for moderate to severe signs of risk or poor mental state. Each patient’s

colour coded tracker was visible to staff on an electronic screen located in the team office.

We saw how staff followed policies for observing patients and for searching patients as

appropriate. For example, staff told us they had to search a patient’s room when a risk item went

missing from one of the communal areas. We saw from records that staff conducted patient

searches only in response to risks based on individual assessment, for example, where they

suspected a patient had brought a cigarette lighter back onto the ward.

Staff told us they did not have any blanket restrictions on patients’ freedom and we did not identify

any at our last comprehensive inspection in November 2016. At this inspection, we found there

were restrictions affecting all patients that were not based on individual risk assessments,

including access to outside areas and access to hot drinks and snacks. The kitchen on the ward

was primarily used for preparing food for the ward, but staff told us that there was a kitchen on the

first floor where patients were supported to prepare meals as part of their treatment. Patients had

access to hot drinks on request. The doors to the garden were locked and there was a notice

advising patients if they wanted access to the garden, they had to ask a member of staff to open

the doors. We were told by someone who visited the ward regularly that there was not always

enough staff to facilities access to the garden at times when patients might want to go. None of the

patients we spoke with at the inspection raised this issue.

The laundry, the craft room and the ward kitchen were all subject to supervised access only, unless patients had been assessed as not presenting a risk in these areas. Access to risk items such as razors or glassware were individually risk assessed by staff for each patient. Staff kept these restrictions under review at their monthly governance meetings. The hospital had a no smoking policy and at the time we carried out our inspection, there were no

patients that smoked.

At the time we carried out our inspection, none of the patients in the service were informal. Staff

told us they would communicate with informal patients personally so they understood they could

leave by asking a member of staff to open the doors.


This core service had 40 incidents of restraint (on 25 different service users) and zero incidents of

seclusion between 1 March 2017 and 28 February 2018.


2018.


restrained


prone restraint

Rapid

tranquilisations

Firshill Rise 0 40 25 0 (0%) 6 (15%)

Core service

total 0 40 25 0 (0%) 6 (15%)

There were no incidents of prone restraint. There have been no instances of mechanical restraint over the reporting period.

The number of restraint incidents reported during this inspection was higher than the zero reported at the time of the last inspection.

At our last comprehensive inspection in November 2016, we told the provider they should ensure that all staff were competent and trained in the use of interventions when dealing with aggression


and violence. The service used an approach called RESPECT, which utilised a philosophy of support and empowerment. Staff were trained in how to use de-escalation techniques with patients and use physical interventions which did not cause pain or panic. Data provided by the service indicated that most staff had received training in RESPECT interventions. Staff used restraint only as a last resort where attempts at verbal de-escalation had failed. We saw that staff encouraged patients to use a room, called the green room to help patients calm themselves down. Staff had found this helpful when patients became agitated and patients were free to leave the room at any time.

The consultant nurse from the community team facilitated regular workshops with staff to help them deal with challenging behaviour from patients. Managers told us they had held three of these workshops over the previous six months and they had another planned immediately following our inspection.

Staff used rapid tranquilisation rarely and only when patients’ behaviour had become extremely challenging and other attempts at de-escalation had failed. The service had a policy and staff received appropriate training to carry out physical health monitoring after administering medication in this way to patients.

The provider reported zero incidents of seclusion between 1 March 2017 and 28 February 2018.

However, in June 2018, there was one episode of seclusion, which had commenced the day prior

to our inspection visit. The service had a seclusion policy in place and had arranged for a nurse to

be on-call so staff could carry out nursing reviews during the night shift. As part of our inspection,

we looked at the one seclusion record and found staff kept seclusion records appropriately.

However, we saw one example where a patient in seclusion did not have a medical review at the

appropriate time because no doctors were available at the right time. Staff told us this was very

unusual and they would report this as an incident.

In this location, there were zero instances of long-term segregation over the 12-month reporting

period.

Safeguarding



This core service made 116 safeguarding referrals between 1 February 2017 and 31 January 2018.

Staff participated in safeguarding training, which included both adults and children. Staff had a good understanding of what constituted abuse and how to recognise it. Support workers sought support from nursing staff where necessary. Staff worked in partnership with social care agencies to progress safeguarding enquiries. The service had comprehensive safeguarding policies, which

Referrals

Adults Children Total referrals

116 0 116


included safe procedures for children visiting the ward. Staff did not allow persons under the age of 18 years onto the ward area but there was a separate visiting room.

At inspection, staff showed us data to confirm that staff had raised 116 safeguarding alerts concerning 17 different individuals.


Staff used an electronic system to record most patient care. In the records we reviewed, staff

recorded information in different places but the information was available to all relevant staff

including agency and bank staff. The manager told us they were implementing new templates onto

the electronic system, which would streamline care planning and ensure staff recorded information

in a consistent place.

The service controlled staff access to electronic records by ensuring staff had individual

passwords. Staff stored other patient information securely locked in the team office and clinic

rooms.


At our last comprehensive inspection in November 2016, staff stored patient medication in the

team office because the clinic room was off the ward area. At this inspection, the trust had

extended the ward to create an air-conditioned clinic room where staff stored and administered

patient medicines. Staff maintained patient medicines charts electronically and a pharmacy

technician from the trust audited medicines management practices weekly. Where the audit

identified deficits, they highlighted this to the nurse in charge who took immediate action. For

example, we saw how, in response to an incident relating to storing medications at the right

temperature, staff had placed a sign on the air conditioning unit in the clinic room reminding staff

not to switch it off.

We checked all the medication records for patients and found staff managed medication

appropriately.

Staff maintained a record of clinic room and medication fridge temperatures. These showed staff

recorded temperatures consistently and staff took action when they were out of range. Medicines

audit reports were presented and discussed at monthly governance meetings and managers put

action plans in place to address areas identified for improvement by the pharmacist.


Providers must report all serious incidents to the Strategic Executive Information System within two working days of an incident being identified.

Between 1 March 2017 and 28 February 2018 there were no Strategic Executive Information System incidents reported by this core service.


We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with Strategic Executive Information System.

The number of serious incidents reported during this inspection was the same as the zero reported at the last inspection.





Staff knew how to report incidents and had access to an electronic reporting system. We saw examples where staff completed incident reports including minor incidents and near misses. At the last comprehensive inspection in November 2016, we told the trust they should ensure that the manager reviewed incidents so they had an overview of what was happening on the ward. At this inspection, we found the figure for outstanding incidents had reduced but there was still a back-log of 71 incidents waiting for manager review. Following the inspection, the trust told us that whilst these incidents had not received management reviews they had all been read at time of entry, and key findings and themes were discussed at handover, safety huddles and in multidisciplinary meetings. We did see evidence that staff discussed incidents involving patients at handover meetings and multidisciplinary meetings.

We saw evidence that staff investigated incidents appropriately and put measures in place to improve practice. For example, managers had built a safety huddle into every shift handover to improve staff and patient safety. At each handover, staff discussed incidents of physical assault on staff and patient-to-patient assaults. Staff also discussed any incidents of observation breaches. Each day, staff put up a poster in the team office identifying the number of days since the last assault incident or breach of observation or dysphagia protocol.

We did not see evidence that staff were involved in reviewing and learning from incidents in the wider trust. Staff talked of receiving emails regarding incidents but these were limited to incidents, which took place within the service. Following serious incidents, managers told us they offered debrief to staff and patients, and we saw examples of this. However, sometimes they struggled to complete these in a timely manner. In the team meeting in May 2018, managers acknowledged difficulties in providing debrief for staff and told us they struggled to support staff to have time out from direct duties in order to reflect and de-brief following incidents. None of the staff we spoke with at our inspection raised this as a concern.




We reviewed the care and treatment records for six out of seven patients on the ward. Each

record contained a comprehensive assessment of their mental and physical health including a

communication assessment, psychological assessment and social and adaptive functioning. Each

patient had a number of care plans in place including a person-centred care plan, a positive

behaviour support plan, a physical health care plan, and a communication plan. However, we

found one patient with challenging behaviour who required a specialist communication

assessment, which staff had not progressed. At the end of our visit, we asked managers to

prioritise this. Following the inspection, we received confirmation that the patient’s communication

needs had been reviewed by a lead speech and language therapist in the trust.

Staff ensured patient care plans, were personalised, and contained clarity about the aims of the

treatment. Care plans were recovery orientated because they were strengths based and covered

the full range of patient need. Staff updated care plans as needed and following review by the

multidisciplinary team.





completed


audit

Capacity &

consent

recording in

Firshill Rise ATS

Firshill Rise ATS

MH - Wards

for people

with learning

disabilities or

autism

Clinical On-going

Awaiting findings

Assessment of

NICE Guidance:

QS142 Learning

disabilities:

identifying and

managing

mental health

problems

Learning

disability

services

MH - Wards

for people

with learning

disabilities or

autism

Clinical On-going Awaiting findings

Greenlight

Toolkit Audit

Learning

disability

services

MH - Wards

for people

with learning

disabilities or

autism

Clinical Not

provided

Green light meeting used

to develop and track action

plan.

Re-audit in 2018

Collaboration

with Primary

Care Clinicians

Service users

on CPA

Provider

wide








solution.

Record keeping

audit 2016/2017

Trust wide Provider

wide



staff on use of




relevant policy.

Audit of risk

assessments

2016/2017

Trust wide Provider

wide






in 2017/18.

Audit of risk

assessments

2017/2018

Trust wide Provider

wide

Clinical audit On-going Await findings

Audits of care

plans

Trust wide Provider

wide


2018


small scale audits.


teams.

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG43

Transition from

children’s to

adults’ services

for young

people using

health or social

care services

Trust wide Provider

wide







transitions

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG13

Workplace

health:

management

practices

Trust wide Provider

wide


2017



future

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG58

Coexisting

severe mental

illness and

substance

misuse:

community

health and

social care

services

Trust wide Provider

wide


2017

Action plan under

development


Staff delivered treatment in line with National Institute for Clinical Excellence, for example, all patients had a named worker to co-ordinate their care. Patient assessments and on-going monitoring identified possible triggers, environmental factors, and functions of the behaviour.

Staff reviewed patients’ medication in line with new guidance produced by NHS England aimed at reducing the over-medication of patients with a learning disability, autism or both.

Staff ensured patients had access to on-going physical healthcare through the health care plan. They supported patients to live healthier lives by providing them with advice and support around, for example, diet and exercise.

Staff participated in clinical audit and benchmarked themselves against other services where appropriate. For example, they compared their incident reporting with other services in the trust and developed initiatives aimed at reducing the number of assaults on staff. Staff participated in an audit aimed at improving access for patients with a learning disability and autism to access mainstream health services.

The psychology team were developing an approach to evidence clinical progress and outcomes with all patients. Key measures included quality of life scores, psychological distress, problem behaviour, psychiatric problems and depression. The team used recognised and evidence based tools for example, they used the CORE-LD assessment and the Glasgow depression scale, both of which were designed to be used with patients with a learning disability. Whilst the approach was still under development, the team had produced a report to show over 70% of the patients profiled had improved psychiatric symptomology, decreased challenging behaviour and decreased levels of psychological distress.


Patients had access to a full range of specialists including, where appropriate, practitioners from

across the trust who could be brought in on a sessional basis. The multi-disciplinary team

consisted of nurses, support workers, an occupational therapist, psychologists, a pharmacist,

psychiatrist and speciality doctor and a speech and language therapist. The team also worked

closely with staff from the trust’s community intensive support service and the community learning

disability team.

The hospital had a policy that new staff on the ward had an appropriate induction and this included

agency and bank staff. However, two people we spoke with told us not all agency and bank staff

had received training in supporting people with learning disabilities and autism and did not always

know how to interact appropriately with patients. When we asked the service about this, they told

us agency staff received basic autism awareness training and regular staff received more in-depth

training and guidance in positive behaviour support. At our inspection visit, we did speak with one

agency member of staff who confirmed they had completed their induction training and knew how

to interact with patients. We did not see any examples where staff interacted inappropriately with

patients.

Notes from team meetings indicated that support staff could participate in non-mandatory training

including physical observations, blood glucose monitoring and care planning. One support worker

we spoke with told us it was difficult for them to get time away from the ward to complete non-

mandatory training.


rates for non-medical staff within this core service was 93%.




Ward name

Total number of


staff requiring an

appraisal

Total number of

permanent non-

medical staff who


% appraisals

Firshill Rise 28 26 93%


Trust wide 1495 1440 96%

The trust’s target rate for appraisal compliance is 90%. As at February 2018, no permanent

medical staff within this core service required an appraisal.

The trust’s target for clinical supervision was 66%

Between 1 March 2017 and 28 February 2018, the rate across this core service was 56%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide. The rate of clinical supervision reported during this inspection was lower than the 64% reported at



sessions required

Clinical

supervision

sessions delivered

Clinical

supervision rate

(%)

Firshill Rise 81 45 56%



Managers told us they provided supervision to staff regularly but over recent months, they had not

done this due to pressure of work and having to provide nursing cover on shift. As part of our

inspection, we interviewed five staff on duty including a mixture of support workers and qualified

nursing staff. Two of the nursing staff we spoke with had been provided with supervision but the

support workers we spoke with told us they had not had regular supervision. Managers told us

supervision rates going forward would improve because they had recruited more nursing staff to

act as supervisors.

Staff had access to team meetings but recently, these had been cancelled in February and March

2018. Support workers told us they did not always have time to attend meetings and when we

reviewed minutes from the team meetings for January, April and May 2018. We saw poor

attendance by support and nursing staff from the ward and there was a lack of clarity about the

dates and frequency of future meetings.


Staff held weekly multidisciplinary meetings and daily handover meetings. The multidisciplinary

team invited support staff to attend but they told us it was difficult for them to get time away from

direct duties to attend meetings. Support staff told us they did not feel involved in decision-making

and did not feel listened to. This finding was supported when we looked at the team meeting


minutes for May 2018 where managers noted that staff did not feel involved in multidisciplinary

meetings and the minutes of these meetings were not always clear. Managers were aware of the

issues and had some ideas to address this including the introduction of collaborative care planning

and ways of making multidisciplinary decisions easier for staff to access.

As part of our inspection, we observed a handover meeting where staff discussed each patient

including any significant incidents within the previous 24 hours. Staff found handovers an effective

way of sharing information about patients’ changing needs and risks.

The team had effective relationships with local community services and external care coordinators.

We observed a planning meeting where staff met with the relevant support agencies and others

involved with the care of the patient to plan their future support needs.


Practice

As of 28 February 2018, 67% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years.

The training compliance reported during this inspection was lower than the 100% reported at the last inspection.

We spoke with the service that provides advocacy support to patients at the hospital and they told

us staff knowledge concerning the Mental Health Act was inconsistent and they had arranged to

provide some advocacy training for staff. However, we found the staff we spoke with at inspection

had a good working knowledge of the Mental Health Act. Managers had clearly identified which

staff needed to complete their mandatory training and had booked them onto future course dates.

The trust had appropriate Mental Health Act policies in place, which reflected current guidance.

Staff could access relevant policies on the trust’s intranet and had access to support and guidance

from Mental Health Act administrators at the trust.

Patients had access to information about independent mental health advocacy including easy-read

versions of information concerning their rights. An advocate visited once per week and referrals to

the advocate was part of the admissions process. Staff had put posters and leaflets up in ward

areas about patient access to the advocacy service.

One patient out of three we spoke with told us staff had sometimes cancelled their section 17

leave due to their unavailability. When we asked the hospital about this, they told us that in the

three months prior to our inspection staff had to cancel four episodes of patient leave due to staff

shortages.

At the time of our inspection, all seven patients were detained under the Mental Health Act. We

reviewed the care and treatment records for six patients. All six patients received support from an

independent mental health advocate and staff had explained to them their rights at regular

intervals. At our last comprehensive inspection in November 2016, we told the trust they should

ensure that the use of advocacy is consistently recorded in patient notes, and that advocates are

routinely invited to take part in decision-making processes to support the patient. At this

inspection, staff had documented advocacy involvement and the date they explained patients’

rights in the care record. We saw in patient notes that an advocate was present at care reviews

and other appropriate meetings to support the patient.


Each month, the ward manager completed an audit of Mental Health Act paperwork including

consent to treatment. As part of the inspection, we looked at recent audits and found that overall

staff applied and monitored the use of the Mental Health Act correctly.



Mental Capacity Act Level 1 and 100% of the workforce had Mental Capacity Act Level 2. The

trust stated that this training is mandatory for all core services for inpatient and all community staff

and renewed every three years.


The trust had an up to date policy on the Mental Capacity Act, including Deprivation of Liberty

Safeguards. Staff were aware of the policy and that they could access it through the intranet.

Staff had a good understanding of the principles of the Act and supported patients to make their

own decisions as much as possible.

At the last comprehensive inspection in November 2016, we told the provider they should ensure

that staff carry out assessments of patients’ capacity to make decisions, thoroughly and in line with

the Mental Capacity Act code of practice. At this inspection, we saw examples where staff had

carried out and documented capacity assessments and best interest decisions as appropriate with

patients.

When staff needed advice or guidance concerning patient capacity, staff could speak with the

deputy ward manager who acted as the lead for mental capacity. The hospital’s lead psychologist

and consultant psychiatrist also provided support and guidance to staff concerning mental capacity

and best interest decision-making.

The lead psychologist carried out an audit of the hospital’s adherence to the Mental Capacity Act

in March 2018. They audited seven records and found some areas of good practice as well as

some practices which required improvement. Staff discussed the results from the audit in the

governance meeting. As a result of the audit, managers had identified recommendations and next

steps. These included reminding staff about the use of capacity assessment forms and using

standard headings in patient care plans to record capacity. Managers also had an action to make

their library of resources more accessible to staff at the point they needed them. Managers told us

they intended to carry out a re-audit in the following three months.

The trust told us that zero Deprivation of Liberty Safeguard applications were made to the Local Authority for this core service between 1 March 2017 and 28 February 2018.

CQC received no direct notifications from Trust between 1 March 2017 and 28 February 2018.

The number of Deprivation of Liberty Safeguard applications made during this inspection was zero. This was the same as the amount reported at our last inspection.




We observed staff interacting with patients on the ward. Staff were respectful and provided

patients with appropriate emotional support when they needed it. All three of the patients we

spoke with told us that staff demonstrated a caring approach and were interested in their well-

being. They told us staff treated them well and behaved appropriately towards them. Two of the

patients we spoke with told us that staff were ‘fantastic’, ‘brilliant’ and could not do enough for

patients. Patients told us staff would knock on their door before entering their room.

Staff had strong links with other services and supported patients to access them as appropriate.

For example, we saw how staff supported a patient to access a local community learning disability

and autism service.

Staff recorded each patient’s cultural, social and religious needs and we saw examples of staff

supporting a patient to access a local church of their choosing. Each patient had a personalised

support plan, which described their communication needs and how they wanted to be cared for,

particularly at times of crisis.

When we interviewed staff, they told us they could and would raise concerns to managers about

any disrespectful or abusive behaviour they saw towards patients. Staff told us they would not be

worried about any consequences of raising concerns and thought managers would act swiftly to

deal with any concerns.

Staff knew how to maintain confidentiality. Each patient had a written agreement in their record

showing which people and organisations staff could share patient information with. Staff

understood the importance of patient confidentiality and showed an awareness of the boundaries.

The last Patient-led Assessments of the Care Environment (PLACE) score for privacy, dignity and wellbeing at this location scored higher than similar organisations.


and wellbeing

Firshill Rise MH – Wards for people with learning disabilities or

autism 93.8%

Trust overall 96.6%


and learning disabilities) 90.6%

Involvement in the care


Staff provided easy-read information for patients to help orient new patients to the ward and

patients told us that staff provided information to them at admission using language they could

understand.

We reviewed the care plans for six patients in the hospital. All six records showed that staff had

involved patients in their care plans and gave them a copy where they wanted one. We saw

evidence that a patient had written into their own care and risk plans using their own language.


Staff encouraged patients to fill out a ‘my questions for the team’ sheet about what help they

needed or whether they would prefer to speak personally with the ward manager or the

responsible clinician.

The hospital employed a speech and language therapist who carried out assessments and made

recommendations for patients with communication difficulties. The therapist met with each

patient’s named nurse to produce a personalised communication plan which included easy-read

information where appropriate.

Patients had the opportunity to be involved in decisions about the service through community

meetings. The patient ‘get together’ group met monthly and included an opportunity for patients to

express new ideas and things they would like to get involved in. Some patients also took part in

recruiting new staff by being part of the interviewing process.

Staff told us they looked at advanced decision making as part of the Mental Capacity Act audit and

would support patients to make advanced decisions where appropriate.


We examined the care and treatment records of six patients at the hospital and found that staff

involved families and carers in the care plan. There was evidence that carers were involved in

care review meetings and one carer we spoke with told us staff updated them weekly on the

progress of their relative. However, except for one carer who we spoke with who told us staff did

involve them and they felt supported by the service, the other relatives and carers we spoke with

in the focus group prior to the inspection and on the inspection visit felt that staff did not provide

them with the appropriate support, and described involvement and communication as poor.

The service produced an information booklet specifically for patients’ carers and families

containing detailed information regarding the treatment on offer at the hospital. Staff told us the

information was based closely on national guidance issued by NHS England. The booklet stated

that staff would offer families independent advocacy support within one week of admission and

that staff would ask regularly if carers needed additional support. Some staff at the hospital told us

this information had only just been put together by the trust and therefore had not been available

to many carers.




Bed management

The trust provided information regarding average bed occupancies for wards in this core service between 1 March 2017 and 28 February 2018.



Firshill Rise 72.5 – 94.76


We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the time-period that was covered.

The staff were proud of the work they had done to reduce the average length of stay of patients at the hospital. They told us that one of their biggest challenges was to help patients progress and not be in hospital longer than necessary. Following our inspection, ward managers provided us with data to show that in 2016, the average length of stay of a patient was 122 days but this had reduced to 85 days in 2017.



Firshill Rise 1 - 265

This core service reported three out of area placements between 1 March 2017 and 28 February 2018.

The placement that lasted the longest amounted to 2027 days.

All of the out of area placements were due to alternative providers better suiting the patients’ care or personal needs.

Number of out of

area placements

Number due to

specialist needs

Number due to

capacity

Range of lengths

(completed

placements)

Number of ongoing

placements

3 3 - 1044 - 2027 0

This core service reported no readmissions within 28 days between 1 March 2017 and 28 February 2018. Staff held discharge meetings with the patient and community providers to ensure patients had a smooth transition to appropriate community services. As part of our inspection, we observed a discharge meeting about a patient who was ready to leave the ward. We saw how staff had good liaison with community support staff to ensure robust support was in place when the patient left the hospital. This meant staff focussed on reducing patient readmissions as much as possible. The ward had a ‘tree of hope’ where patients getting ready for discharge could write messages on a leaf about what they had learned.



Between 1 March 2017 and 28 February 2018 there were 12 discharges within this core service. This amounts to 1% of the total discharges from the trust overall (804).

Staff planned patients’ discharge as part of the assessment process and reviewed these as part of

multi-disciplinary meetings. The team completed care and treatment reviews with patients to make

sure they had the right support to be able to live safely in the local community. From the period, 1

April 2017 to 31 March 2018, staff carried out nine reviews on seven patients. Of those patients,

four patients were discharged to onward placements, two patients remained in active treatment

and one patient was transferred to locked rehabilitation unit.

Since the last comprehensive inspection, the trust had built an appropriate seclusion facility on the ward so staff could support patients where their behaviour escalated, rather than transferring them to another ward or service.

There were 27 delayed discharges between 1 March 2017 and 28 February 2018. Due to delayed discharges being reported on month by month basis patients can be captured multiple times within the data.

Referral to assessment and treatment times was not provided for this service. We saw that where

possible, patients had a care and treatment review prior to admission. The hospital told us the

reviews were designed to determine whether in-patient care was the most appropriate treatment

and to ensure that all community alternatives had been explored.


The 2017 Patient-Led Assessments of the Care Environment (PLACE) score for ward food at this location scored higher than similar trusts.


Firshill Rise MH – Wards for people with learning disabilities or

autism 99%

Trust overall 96.4%


The ward was located in a purpose-built building called Firshill Rise. The building had many

unique design features including the colour scheme, which met the King’s Fund ‘enhancing the

healing environment’ standards. Patients had their own bedrooms all with en-suite facilities. The

hospital had one self-contained flat designed to aid and support independent living.

Patients told us they could personalise their bedrooms and had somewhere secure to store their

possessions. Staff told us they were looking to install safe boxes in patient rooms so they could

store their money. In the meantime, staff looked after patients’ money and kept records when

patients wanted take money out.

Staff and patients had access to four comfortable lounges including a female only lounge, an

activities room, a therapy kitchen, a multi-faith room, a fitness room and a de-escalation suite.

Since the last comprehensive inspection, the hospital had built a clinic room and a sensory room

on the ward so patients did not have to move off the ward to access these facilities. The trust had


also built a seclusion room for use in appropriate circumstances with patients with challenging

behaviour. Patients had access to a garden area with some interactive games. The hospital had a

dedicated meeting room where patients could meet visitors.

Patients were allowed their mobile phones on the ward and this was individually risk assessed and managed. Patients had personal access to the internet on the ward if they had their own laptop or electronic device. Staff gave patients a Wi-Fi password. Patients were also able to use the ward cordless phone on request. The patients we spoke with told us they liked the food. None of the patients staying in the hospital

had unsupervised access to the kitchen and had to ask staff if they required drinks or snacks

outside meal times. Staff placed notices on kitchen doors to prompt patients to ask staff if they

required these.


The occupational therapist worked with support staff to provide some activities for patients aimed

at education including cooking and gardening skills. Occupational therapy staff worked with some

patients to access college and voluntary work opportunities.

We saw evidence in care records that staff encouraged patients to maintain contact with their families and carers. However, we saw a sign on the ward about visiting times for carers being limited to certain times of the day. When we asked staff about this, they told us that relatives and carers could visit outside these times provided they advised staff in advance. They gave us an example where they had been able to facilitate visits for a carer who could not make the stated times. None of the patients or carers we spoke with raised concerns about visiting times. The ward manager was the main point of contact for carers and we found no carer’s forums in place. Staff told us they intended to develop this area and had produced a detailed information booklet aimed at families and carers.


The ward had wheelchair access throughout and staff carried out mobility assessments where

patients needed it. Staff had access to hoists and other equipment to support patients with mobility

needs.

Patients told us staff provided information about how to complain and we saw information in the ward areas about local services including information about patients’ rights. This information was available in easy read format. We found some of the activities and materials available for patients were not always age appropriate and were more suitable for young children. Staff told us they had access to interpreter facilities through the trust. They told us the trust could produce information in different languages and different formats where required. They gave us an example of how they supported a patient with reduced hearing. Some staff had been trained to use British sign language with patients. The ward employed housekeeping staff to prepare meals on site. Staff told us there was a menu review taking place in the hospital led by occupational therapy staff and supported by a dietician from the trust. Staff could prepare meals according to patients’ dietary requirements. For example, staff told us that they had a patient who would only eat fish. Staff ensured patients had a choice about the food they ate including any religious requirements they had. Patients had access to a


multi-faith room and we saw examples where staff supported patients to access a local church of their choice.

Listening to and learning from concerns and complaints.

This core service received two complaints between 1 March 2017 and 28 February 2018. Both

were still under investigation at the time of the provider information request submission.

The patients we spoke with told us they knew how to make a complaint and raise concerns. We

saw information on the ward about the hospital’s complaints procedure and patients could raise

issues in community meetings. However, we saw in the community meeting notes on 24 April

2018 that patients had asked for the television in one of the patient lounges to be fixed but this had

not been done when we carried out the inspection two months later. Following our inspection, we

asked the provider to attend to this and they confirmed they would. Staff told us they knew that

patients could make a formal complaint and they knew the process to enable them to do this.

We saw that managers discussed complaints as a standing item at monthly governance meetings

but when we reviewed notes from team meetings, we could not see that managers had cascaded

any information to staff regarding the outcome of formal complaints. For example, the hospital had

partially upheld a complaint made by a patient’s family at the end of March 2018. When we

reviewed the notes from the team meetings for April and May 2018, we could not see that staff

had received any feedback about this complaint. However, we noted that at their governance

group in May 2018, managers had an action to provide feedback to the team about the outcome of

the complaint and we could see that on the day of our inspection, some staff had participated in a

workshop aimed at learning from the complaint. At the time of our inspection, the service had one

outstanding complaint that the trust had investigated and were in the process of responding to this.

Some of the carers we spoke with told us they had complained informally but had not received a

satisfactory response. When we raised this with managers, they told us the service had received

some negative feedback from carers through the feedback box based in the reception area.

Managers told us they had offered some carers the opportunity for meetings between themselves

and nursing staff to discuss concerns.

This core service received zero compliments during the last 12 months from 1 March 2017 and 28

February 2018.

Following the inspection, staff provided evidence that in June and July 2018, the service received

five compliments. These included compliments from carers, patients and other organisations.



Leadership

A ward manager managed the ward with support from two deputy managers. At each shift, staff

had support from a nurse in charge. The manager we spoke with was not a specialist learning

disability nurse but had received training in positive behaviour support approaches from the nurse

consultant who provided clinical leadership to the service. A psychiatrist and a consultant clinical

psychologist provided further clinical leadership.

The leaders had a good understanding of the services they managed and could explain how the

team worked together including some of the challenges they faced. They worked closely with staff

and patients to provide direct care. The ward manager had been providing nursing cover for a

significant number of shifts and had a good understanding of the needs of the service. During our

visit, we saw managers interacting with staff and patients to deliver treatment.

Managers told us they had opportunities to develop their leadership skills but some of them had

not been able to take full advantage of them due to staffing levels. However, the service had

recently recruited permanent nursing staff and some managers were hopeful that a more settled

period would follow. We did not see evidence that staff below manager level had access to

leadership development opportunities.

Vision and strategy

The staff we spoke with knew what the trust’s vision and values were as these were visible on the

intranet and available to all staff. Staff told us there were clear links to the trust’s vision and values

in their annual performance appraisals.

Staff could tell us what the vision and values meant for them in delivering positive outcomes with

patients and their families. When we observed staff working with patients and with colleagues, we

could see that they demonstrated the trust’s values, for example respect, compassion and

partnership.

Managers told us that front-line staff had the opportunity to contribute to service development

through attendance at local governance meetings but the staff we spoke with told us they found it

difficult to get time away from delivering front-line care. Managers confirmed that one of their

biggest challenges was supporting the team with time away from the ward to get involved in

development multidisciplinary and other meetings.

Staff told us they were part of a new crisis and emergency care network within the trust and were

working closely with their colleagues on improving quality of care. Most of the staff we spoke with

were positive about being part of the new structure but some staff we spoke with thought it would

lead to a reduction in the quality of care provided by the service. Managers were in discussion with

local commissioners about staffing levels, bed numbers and reinvesting resources into a

community intensive support function for patients.

Culture

Managers told us one of their biggest challenges was supporting the team with time away from delivering direct care and reducing the risks to staff stress and low morale. They had conducted a staff stress survey in October 2017, which identified high levels of stress across a number of domains including demands, control, and support. Managers told us that they treated the results with some caution because staff selected themselves for participation and less than a third of the


workforce took part. When we spoke with staff, they told us the work was stressful and they did not get enough time away from delivering direct care.

Based on the results of the stress survey managers had put some key actions in place, including increased access to reflective sessions, the implementation of acceptable behaviour agreements with patients, staff meetings, and workplace well-being support. When we spoke with staff and looked at notes from meetings, we could see that managers had plans in place to implement regular reflective practice sessions with staff and had discussed implementing behaviour agreements with patients but these initiatives were not yet in place when we inspected the service. We did see evidence that managers had communicated with staff about health and well-being support. The trust had information on the intranet for staff about networks and support groups, personal and professional development, physical, and mental health wellbeing groups. Some of the staff we spoke with did not feel positive about working for the provider and felt they were not involved much in decision-making. They did not feel listened to by members of the multidisciplinary team regarding patient care. Managers we spoke with were aware of these issues and carried out a teamwork and safety survey every three months. They monitored the results through local governance meetings and had a management action plan covering a broad range of staff support issues. The staff we spoke with told us they felt able to raise concerns without fear of retribution and this was confirmed by the teamwork survey carried out by the hospital from December 2017 to February 2018. Although only 20% of the workforce took part in the survey, they reported that the service encouraged them to report safety concerns. Staff told us they knew how to use the whistleblowing procedures and knew there was someone in the trust who they could approach about speaking out. Managers could name the trust’s freedom to speak up guardian and explain the role they played. Some teams worked well together, for example, staff told us doctors and nurses worked well together, and managers valued nursing input. However, the latest team survey indicated that staff thought decision-making did not utilise all the input from relevant personnel and that the service did not resolve disagreements appropriately. Managers told us the trust supported them to deal effectively with conduct and capability issues within the teams and there were no reported cases of bullying or harassment within the teams. Managers told us they carried out annual appraisals with staff and these supported them to have conversations with staff about career development. The sickness absence rates for this core service were higher than the average for the provider. Managers attributed this to high levels of staff stress and assaults on staff from patients. Managers had introduced measures such as safety huddles and improved handovers as a way of reducing staff stress and assaults from patients.

During the reporting period, there were two cases where staff have been either suspended, placed under supervision or were moved to a different ward. Both were cases of suspension.


Governance

Overall, the hospital had systems and procedures to ensure that premises were safe, clean, and

well managed. Staff carried out regular audits covering the full range of activities including the care

environment, medicines management, Mental Health Act and Mental Capacity Act, training,

patient records, supervision and appraisal. Managers monitored audit activities through their local

governance meetings each month. They ensured that staff were trained and that patients were

assessed, treated and discharged in line with trust protocols.


When managers carried out audits, for the most-part, they acted on the results. For example, we

could see that they had put measures in place to reduce assaults on staff and they monitored

whether assaults were decreasing over time. Data supplied by the hospital identified that from

December 2017 to February 2018, the number of assaults on staff had fallen month by month from

a peak of 50 in November 2017.

Managers had recruited new staff and despite concerns from front-line workers, they operated

over and above their establishment levels for numbers of qualified nurses and support workers.

Managers had put forward a business case to keep staffing at these levels and were awaiting the

outcome of negotiations with service commissioners.

However, we found the hospital did not have effective systems in place to ensure support staff

received supervision. The support staff we spoke with told us they had not received supervision

and the trust reported low compliance rates. We also found that managers allowed some staff to

work on shifts where they had not completed an induction and on 13 shifts in the last three months

there were not always a minimum of three staff on duty trained to the required levels for managing

violence and aggression and restraint.

We found the hospital had a well-embedded incident reporting system and staff discussed patient

incidents at every handover meeting. We saw evidence that managers provided de-brief for

patients and staff following serious incidents. We also found evidence that systems for learning

from incidents and complaints had improved but managers had not embedded these processes

into the service. For example, we saw that some staff were involved in a workshop aimed at

learning from a recent complaint but we did not see evidence that managers routinely shared

lessons learned from non-patient incidents or from other parts of the trust with front-line staff.

We did not see evidence that learning from non-patient related incidents formed part of team

meetings and managers had 71 incidents still requiring manager review. This was something we

told the provider they should take action about at our last comprehensive inspection in November

2016. When we spoke with the provider, they told us that staff discussed incidents involving

patients at every handover and the psychology team monitored the frequency and severity of

incidents involving each patient. They showed us copies of their clinical tracker reports. However,

we could not see that staff had routine access to information concerning non-patient related

incidents. We could see from service action plans that managers had plans to address the amount

of incidents requiring review but the systems were not effective to stop this from occurring again.

Staff understood referral arrangements and care pathways with providers both internally and

externally. They had strong working relationships with other providers to meet the needs of their

patients.


Managers were aware of the high number of assaults on staff and had noted this on the local risk

register, which they monitored at monthly governance meetings. They also identified that the

service had been operating on high levels of agency and flexible staff and had escalated these

concerns to the relevant care network risk register located in the trust. The concerns identified on

the local risk register matched the concerns of staff in the service.

The trust acknowledged that, following a benchmarking exercise, they needed to carry out further

work to map staffing capacity to respond to incidents including the amount requiring review against

other clinical demands. Senior managers in the care network had set up a red flag escalation alert

when the numbers of non-reviewed incidents hit a threshold and local managers monitored

numbers through local governance meetings. The trust archived some incidents with an impact


rating of lower than moderate. However, local managers still had 71 outstanding incidents to

review.


Staff had access to equipment and technology to carry out their role including desk space where

staff could use computers and telephones. The hospital had an electronic patient records system

and intended to introduce collaborative care planning to streamline care plans and make multi-

disciplinary decisions easier for staff to access.

Staff were aware of the importance of security and confidentiality in managing patient information.

They had received training in information governance and were familiar with the trust’s procedures

for managing and storing confidential data.

Engagement

Patients and carers had access to up-to-date information about the hospital through the trust’s

website, which had information for patients as well as information for families and carers. The

hospital had produced a new information pack with detailed information for families and carers and

the trust website provided information for staff about the work of the trust.

We saw that carers had access to a feedback box in the reception area of the building where the

hospital was located. Staff told us they had not received much feedback from this mechanism but

were looking at more meaningful ways to engage patients’ families and carers.


Staff participated in a trust initiative to enable people with a learning disability and autism to access mainstream health services. They carried out several audits and took a number of actions to improve health outcomes and share good practice. These included improved awareness and training for staff on learning disability and autism and the development of accessible information and resources across the service.

Staff in this service were part of an initiative called STOMP which stood for ‘stop overmedication of people with a learning disability, autism or both’. Staff convened a stakeholders meeting with internal and external service providers to identify ways to reduce and stop the over prescribing of antipsychotic medication in learning disability services across Sheffield.

Staff in the service used a variety of quality improvement methods including, safety huddles and structured discussions for staff aimed at improving the emotional impact of assaults on staff well-being.

Providers are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.



Community-based mental health services for adults of working age



female, mixed)

Fulwood House

Community

Enhancing

Recovery Team

(CERT)

44 Mixed

Fulwood House Home Treatment

Team 44 Mixed

Fulwood House

Mental Health

Recovery Service

North

44 per week

(176 per month) Mixed

Fulwood House

Mental Health

Recovery Service

South

44 Mixed

Fulwood House

Early Intervention

in Psychosis

Service

44 Mixed

Sheffield Health and Social Care NHS Foundation Trust’s community services for adults of working age core service comprised five teams. During this inspection we inspected three teams based at two sites. These were the Mental Health Recovery Service North, the Home Treatment Team and the Community Enhancing Recovery Team.

The community service for adults of working age delivers three broad levels of treatment and support, which are tailored to the individual needs of each service user:

• Enhanced support - intensive and assertive treatment and support for service users who present with a high level of enduring and/or complex mental health needs who would otherwise disengage.

• Active Recovery - treatment and support to service users who present with enduring and/or complex mental health needs.

• Case Management - low level support for service users requiring less frequent contact, for example, service users collecting medication monthly with no other unmet needs or requiring regular but minimal contact to ensure that universal support is effectively meeting their needs.

The Home Treatment Team provides short term intensive mental health support to individuals who would otherwise require admission to hospital.

The Mental Health Recovery Service North provides multi-disciplinary care to people with complex mental health issues. It aims to promote an optimum level of recovery, independence and social inclusion for each individual.

The Community Enhancing Recovery Team is designed as an intensive rehabilitation and recovery team to deliver bespoke packages of care to people in their own homes as an alternative to hospital admission. The service provides support for people currently placed in locked rehabilitation hospitals, often outside of the city returning to Sheffield, living in their own accommodation.


The community services for adults of working age had recently undergone a reconfiguration exercise at the time of our inspection. The aim of the reconfiguration was:

• to ensure quality of clinical and operational leadership

• to operate consistently across the City including standardised assessment and treatment in line with National Institute for Health and Care Excellence guidelines and quality standards

• to articulate and understand the definition of each component part of the service offer for staff, the people who used the services and referring agencies

• to ensure a well governed, performance managed operating system with leaders empowered to manage flow in community services

• to make the service financially affordable and sustainable over the next two operating years

• to ensure a consistently effective workforce through motivated staff with relevant skill sets

• investing in staff to bring about continuous service improvement.




Staff adhered to the service’s security arrangements. All visitors to the service were required to sign in and out and provide personal identification. There were no call alarms in the rooms at the service bases, however, patients were normally seen at their homes or alternative location of their choice.

The buildings were clean and tidy, furnishings were well maintained, and of a wipeable material which complied with infection control procedures. Health and safety documentation for the services, including certificates for gas, electrical, legionella, fire and other tests were in-date.

Staff undertook regular assessments of the environment and rectified any issues identified. For example, anti-ligature pull cords had recently been fitted in the disabled toilet and coat hooks had been removed from interview and activity rooms at the Mental Health Recovery Service North as they had been identified as potential ligature points. A ligature point is anything which could be used to attach a cord, rope or other material for hanging or strangulation. Signage was posted at both sites to show who the fire wardens and first aiders were.

Staff adhered to infection control procedures. Hand sanitising gel was available throughout the service and there were washing facilities throughout the service buildings. The services had their own domestic staff who regularly cleaned the environment. Equipment used to deliver care and treatment was clean and in working order with stickers to indicate when they had been serviced.

The Community Enhancing Recovery Team could access emergency medicines and equipment from the trust’s inpatient service when required.

The Home Treatment Team and Mental Health Recovery Service North shared a supply of stock emergency medication. These services could also order urgently required medication from the trust’s pharmacy department at short notice which could be either collected or delivered.

Safe staffing

Definition


Establishment – All posts allocated and funded (e.g. substantive + vacancies). Any negative numbers indicate an over-establishment.



Total number of substantive staff leavers 1 February 2017- 31 January 2018

34.6 N/A

Average WTE* leavers over 12 months (%) 1 February 2017- 31 January 2018

9% 13%






11% 5%


6% 5%





Number of vacancies, qualified nurses (WTE*) At 31 March 2018 -4 N/A


Qualified nurse vacancy rate At 31 March 2018 -5% N/A


Bank and agency Use





(Qualified Nurses)

1 March 2017 and 28

February 2018 0 N/A



1 March 2017 and 28

February 2018 7 N/A



1 March 2017 and 28




1 March 2017 and 28

February 2018 0 N/A



1 March 2017 and 28

February 2018 0 N/A


This core service reported there was a 5% over-establishment of registered nurses at 31 March 2018.

This core service reported an overall vacancy rate of 5% for nursing assistants.


This core service has reported a vacancy rate for all staff of 8% as of 31 March 2018. This was not comparable to the rate reported at the last inspection (between 1 August 2015 to 31 July 2016).


Team Vacanci

es

Establishme

nt

Vacanc

y rate

(%)

Vacanci

es

Establishme

nt

Vacan

cy rate

(%)

Vacanci

es

Establishme

nt

Vacan

cy rate

(%)

Adult

Home

Treatme

nt

-4 27 -15% -2 8 -25% 18 65 28%

MH

Recover

y North

2 13 15% 3 9 33% 9 34 26%

Early

Interventi

on

Service

2 18 11% 0 5 0% 5 41 12%

CERT -1 9 -11% 2 38 5% 1 57 2%

MH

Recover

y South

-3 13 23% 0 6 0% -14 36 -39%



Core

service

total

-4 80 -5% 3 66 5% 19 233 8%

Trust

total 32 433 7% 15 353 4% 68 1339 5%



staff

Shifts filled by

agency staff



Home

Treatment

Team

0 188 0 7

Core service

total 0 188 0 7

Trust Total 32,394

4977

(15%*)

7252

(22%*)

900

(3%*)

*Percentage of total shifts has only been provided for trust wide figures. The available shifts data was not

provided for this core service. We are therefore unable to provide proportions filled information for this core service.


staff

Shifts filled by

agency staff


or agency staff

Home

Treatment

Team

0 23 0 0

Core service

total 0 23 0 0


(37%*)

5623

(9%*)

1760

(3%*)

*Percentage of total shifts have only been provided for trust wide figures. The available shifts data was not

provided for this core service. We are therefore unable to provide proportions filled information for this core service.

This core service had 34.6 (9%) staff leavers between 1 March 2017 and 28 February 2018. This was slightly lower than the 11% reported at the last inspection (1 August 2016 and 31 July 2017).



West CMHT Senior Medical 0 1 60%

CMHT's Central 0 4.6 26%

South East CMHT 3.0 6 20%

North CMHT Admin 0 2 18%

West CMHT 1.4 4.4 18%

South West CMHT 1 4.8 15%




South East CMHT Admin 0.8 1 11%

West CMHT Admin 0 1 8%

MH Recovery North 36.8 2.5 7%

North CMHT 2 2 6%

South West CMHT Admin 0.8 0.6 6%

CERT 58.3 3 5%

Early Intervention Service 32.3 1 4%

MH Recovery South 41.5 0.8 2%

Adult Home Treatment 34.6 0 0%

North CMHT Senior Medical 0.8 0 0%

South East CMHT Senior Medical 0 0 0%

South West CMHT Senior Medical 0 0 0%


Trust Total 1351.6 129.6 8%

The sickness rate for this core service was 6% between 1 February 2017 and 31 January 2018. The annual sickness rate was similar to the annual sickness rate of 6% reported at the last inspection in 31 July 2016.

Sickness absence figures for staff were high at the Mental Health Recovery Service North. They were an average of 14% in the 12 months prior to our inspection, twice the annual average figure for this core service, and had reached 20% in the final month. This was having an impact on staff morale and caseloads although there was no evidence this was affecting patient and staff safety. The reasons for sickness absence included work related stress as well as other more common health problems. Staff reported their caseloads were between 40 and 50 patients each because of other staff being absent due to sickness leave and were not manageable. Caseloads were monitored by managers during staff supervision sessions. Some staff members were on sickness absence due to work-related stress. However, the trust had been proactive by employing four agency staff members to cover sickness absences. Two of these staff had worked at the service for several months and were familiar with the way the service operated. The other two agency staff had recently joined the team and were still familiarising themselves with the service. Vacancy and sickness absence figures for the Home Treatment Team were also high at an average of 18% over the last 12 months, 11% higher than the annual average for this core service. However, at the time of inspection, some posts had been filled and staff said this had improved working practices and morale within the team.

Team Total % staff sickness Ave % permanent staff


(at latest month) sickness (over the past year)

Adult Home Treatment 18% 18%

MH Recovery North 20% 14%

South East CMHT Admin - 13%

MH Recovery South 8% 11%

North CMHT 47% 10%

South East CMHT 44% 7%

Early Intervention Service 6% 6%

CERT 4% 5%

West CMHT 2% 5%

West CMHT Admin - 4%

South West CMHT 0% 3%

South West CMHT Admin 0% 3%

North CMHT Admin - 2%

North CMHT Senior Medical 0% 2%

CMHT's Central - 1%

South West CMHT Senior Medical - 1%

West CMHT Senior Medical - 1%

South East CMHT Senior Medical 0% 0%


Trust Total 8% 7%

Managers at the services we inspected were unable to give a clear explanation as to how staffing numbers were calculated. They stated that this was because the staffing figures had had been calculated before they had started working in their teams. However, we had no concerns about the actual establishment levels of staff at either service and there were plans in place to recruit two nurses above actual establishment levels at the Mental Health Recovery Service North. The potential for an additional four care co-ordinators being established at the Mental Health Recovery Service North was being considered as part of the next round of staff recruitment to the service.

All three services had full time psychiatrists. They also had access to an additional psychiatrist from the trust to cover leave or sickness when required. For out of hours, the trust’s on call psychiatrists were utilised.


Mandatory training

The compliance for mandatory and statutory training courses at 28 February 2018 was 87%. Of the training courses listed, six failed to achieve the trust target and of those, two failed to score above 75%. These were Respect level one training and intermediate life support.


Key:








Health and Safety (Slips, Trips

and Falls) 97% 80% 97%














Deprivation of Liberty

Safeguards Level 0 79% 80% 80%



Dementia Awareness (inc

Privacy & Dignity standards) 78% 80% 85%




However, compliance figures for mandatory training were low for staff at the Mental Health Recovery Service North at the time of our inspection, with 69% of clinical staff and 24% of social workers compliant with their mandatory training. Figures below 75% compliance included mandatory training in basic life support, health and safety, preventing falls, fire safety, Mental Capacity Act, dementia, autism awareness, domestic abuse and safeguarding. The low figures were partly because some of the staff members eligible for mandatory training were on long-term sickness absence.

Mandatory training compliance figures were also low at the Home Treatment Team in relation to dementia awareness, medicines management awareness, respect levels one and two and safeguarding children.


However, compliance figures for the Community Enhancing Recovery Team were high and were 96% overall.



The trust had a risk assessment tool called the Detailed Risk Assessment and Management Plan. The tool recorded each patient’s history and included templates for making referrals to GPs and other health professionals. The Detailed Risk Assessment and Management Plan tool included the patient’s risk to themselves and others, details of any self-neglect, risk of exploitation, risks to dependants and other risks.

Staff at the Mental Health Recovery Service North did not regularly update risk assessments within patients’ records. We looked at 24 patient risk assessments; nine at the Mental Health Recovery Service North, seven at the Community Enhancing Recovery Team and eight at the Home Treatment Team. Risk assessments were in place for all patients at the Community Enhancing Recovery Team and Home Treatment Team and staff had updated regularly. However, seven of the nine risk assessments at the Mental Health Recovery Service North had not been updated for over six months. The service manager told us that they expected risk assessments to be updated every six months as a minimum. We also noted that a letter dated 18 April 2018 had been returned by a GP to say a patient was now under the care of a different GP surgery. However, staff had not changed the GP's details in the patient’s record, which could cause delays if staff needed to contact the GP urgently over concerns about the patient's physical health status.

The services made good use of crisis plans and advance decisions. Care records contained details of health professionals to contact when patients were in crisis and actions to take, for example, one patient’s crisis plan detailed the distraction techniques staff should use to calm the patient down. We saw evidence in patients’ care records that staff assisted patients who wanted to make advance decisions about their care and treatment choices when requested.


Staff responded promptly to sudden deterioration in a patient’s health. Staff consulted the multidisciplinary team and emergency psychiatrists when they identified any concerns. There were enhanced support teams within the Mental Health Recovery Teams who provided a crisis response and a higher level of support outside a patient’s scheduled planned care when required.

The services had good lone working practices. These included a buddying system, use of mobile phones, a signing in and out register and boards in the reception offices which gave details of the time and location of any external visits to patients.

Safeguarding

A safeguarding referral is a request from a member of the public or a professional to the local authority or the police to intervene to support or protect a child or vulnerable adult from abuse. Commonly recognised forms of abuse include physical, emotional, financial, sexual, neglect and institutional.


This core service made 1300 safeguarding referrals between 1 February 2017 and 31 January 2018, all of which concerned adults only.

Referrals

Adults Children Total referrals


85

103110 109

130

119112

92

137

102

80

121

0

20

40

60

80

100

120

140

160

Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18

Total Safeguarding referrals

Staff knew how to raise safeguarding alerts; they could provide examples of the possible signs of abuse. Examples of referrals that had been made included instances when patients had been exploited financially by friends or family members. However, safeguarding training compliance was low for staff at the Mental Health Recovery Service North despite the training being mandatory; 64% of nursing staff had completed safeguarding children level 2 and only 22% of social workers had completed safeguarding adults level 2. Training compliance figures at the other services we inspected were between 90 and 100%.

The trust had policies and procedures in place in relation to equality and diversity to protect the people who used the service from discrimination and harassment. The trust also employed transcultural workers and spirituality leads to address issues around culture and religion. The Community Enhancing Recovery Team also held weekly firefighting meetings and case formulation meetings during which, staff discussed issues in relation to safeguarding and protecting individuals from discrimination and harassment.

Sheffield Health and Social Care NHS Foundation Trust submitted details of one external case review which was commenced or published in the last 12 months that relate to this core service. The trust has one on-going case relating to a young person. The services involved were the Early Intervention Service, Liaison Psychiatry, Home Treatment Team and Crisis House.


Staff had access to all the information they needed to deliver safe patient care and treatment. The service used an electronic care records system, which staff could use effectively and arrangements were in place to enable all staff to share patient information both internally and externally with other health professionals.

1300 0 1300



There were safe procedures in place for the transportation, recording, storage and disposal of medicines. The Community Enhancing Recovery Team only stored medication for patients who required support with self-administration. The room at the Community Enhancing Recovery Team used for storing medicines had been as high as 27 degrees Celsius for a few days prior to our inspection but staff had reported this to senior managers and plans were afoot to move the medicines to a cooler room.

The Mental Health Recovery Service North did sometimes hold controlled drugs at the service but this was rare. On the occasions controlled drugs were held, the team liaised with the accountable officer who worked in the trust’s pharmacy department to ensure the correct measures were in place. The service’s senior practitioner nurse was the lead with local medication management arrangements. Staff reviewed patients’ medication and the effects of medication on patients’ physical health during care programme approach meetings, multidisciplinary meetings, and other team meetings. These reviews were in line with guidance from the National Institute for Health and Care Excellence.

We reviewed 25 medication cards across the three services and found they were in order.



Between 1 March 2017 and 28 February 2018 there were 14 STEIS incidents reported by this core service. Of the total number of incidents reported, the most common type of incident was Apparent/actual/suspected self-inflicted harm with 11 incidents.


We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with STEIS. There were 14 incidents in STEIS and the trust provided information on 15 serious incidents.

The number of serious incidents reported during this inspection was lower than the 18 reported at the last inspection.

Type of incident reported on STEIS

Number of incidents reported Apparent/actual/suspected

homicide meeting SI

criteria

Apparent/actual/suspected

self-inflicted harm meeting

SI criteria

Medication

incident

meeting SI

criteria

Total

Early Intervention Service 3 3

CMHT SW Access 2 2

CMHT SW Recovery 1 1 2

CMHT SE Home Treatment 1 1

North Home Treatment 1 1

CMHT North 1 1

CMHT SW Home Treatment 1 1

CMHT West 1 1

CMHT West Recovery 1 1


Mental Health Recovery South 1 1

Total 1 11 2 14



In the last two years, there have been no ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.

Staff at the services knew how to report incidents. Staff had access to the trust's electronic reporting system. Staff gave examples of the types of incidents that were reported which included assaults, verbal abuse, medication errors, high caseloads and low staffing levels. The trust’s patient safety team fed back any lessons learned from incidents to staff and managers fed back directly to staff members who had raised incidents. Manager debriefed and offered support to staff following serious incidents. The services also held reflective practice meetings during which staff were able to consider findings and learning points from incidents, which had been investigated. We also saw evidence in minutes of team meetings that incidents and associated issues were a standing agenda item. At the time of our inspection visit, an incident in which a member of staff had been threatened by a patient had recently occurred. Staff were debriefed and offered support afterwards. The trust was conducting a review of the incident to identify any lessons that could be learned for the future.

Staff understood the duty of candour. They described being open and transparent, offering patients and families a full explanation and apology when something went wrong, and keeping them regularly informed of any investigations.




We looked at 24 patient care records across the three services we inspected. Four out of the 24 records did not include details of a comprehensive mental health assessment of the patient. The records for the Community Enhancing Recovery Team and Home Treatment Team all contained evidence that patients had undergone a comprehensive mental health assessment.

Out of the 24 records we looked at, 23 contained evidence that staff had developed care plans in collaboration with the patient or their carers and all care plans were personalised, holistic, recovery based and included goals for each patient.


Staff provided a range of care and treatment interventions, which were in line with guidance from the National Institute for Health and Care Excellence. For example, the services’ psychology teams offered interventions which included cognitive behaviour therapy, eye movement desensitisation and reprocessing and compassion focussed therapy. Staff also provided patients with support and advice around opportunities for education, employment, housing and benefits and living skills.

Staff ensured patients’ physical healthcare needs were met and encouraged patients to attend annual health checks and other appointments with GPs and other health professionals. Care records contained evidence that staff were monitoring patients’ physical healthcare and involving other healthcare professionals where appropriate. For example, one record showed that staff carried out monthly blood tests on the patient, conducted regular electrocardiogram tests to monitor the effects of their medication and referred the patient to their GP to review their medication. Another record contained evidence that staff were carrying dietetic assessments and providing advice to the patient about nutrition. Staff audited their own caseloads to ensure that physical health information was up to date and accurately reflected their patients’ current physical health status. Staff liaised with the multidisciplinary team and patients’ GPs if they had any concerns around a patient’s physical healthcare.

Staff encouraged patients to live healthier lifestyles by promoting exercise, eating healthily and smoking cessation. Posters and information about support, treatment and advice about cancer screening, diabetes and a range of other health related issues were also available in the waiting area.

The services used recognised ratings scales to rate patients’ severity and outcomes. These included Health of the Nation Outcome Scales, Recovering Quality of Life, and the clustering tool.

The services used online facilities to support patients effectively. This included online friends and families tests, which staff used to gain feedback and suggestions from the people who used the service and the purchase of tablets for mobile working. Staff also provided patients with details of the services’ and wider trust’s social media pages and website.




completed


audit

National Audit

of Early

Intervention

Services

Early

Intervention in

Psychosis

Service

MH -

Community-

based mental

health

services for

adults of

working age.

Clinical

Data

collection

completed

January

2018.

Awaiting

publication

Awaiting publication of

results. Preliminary results

to be shared.



completed


audit

of report

Care Pathway

for Early Onset

Dementia

CMHT North

MH -

Community-

based mental

health

services for

adults of

working age.

Clinical Feb-17

Acknowledged need to

develop specific standards

for this referral pathway.

Physical Health

Monitoring in

the Early

Intervention

Service

Early

Intervention in

Psychosis

Service

MH -

Community-

based mental

health

services for

adults of

working age.

Clinical Apr-17

The results of this audit

were presented to the

members of the weekly

EIS Microsystems team.

The EIS team plan to

address the issues raised

in order to develop

changes in team practice

capable of driving the

necessary improvements.

Physical Health

Monitoring in

Patients on

Antipsychotics

South East

Home

Treatment Team

MH -

Community-

based mental

health

services for

adults of

working age.

Clinical Nov-17

Findings shared with the

South East Home

Treatment Team for local

improvements.

Clinical Audit to

review case

discussions of

newly allocated

service users

within MDT

meetings

West Recovery

team

MH -

Community-

based mental

health

services for

adults of

working age.

Clinical Oct-17

Detailed information and

discussion to be

documented on the

electronic care record

instead of MDT minutes.

Local audit of

completion of

Physical Health

Review forms

and appropriate

action taken

South West

Community

Mental Health

Team – Home

Treatment Team

MH -

Community-

based mental

health

services for

adults of

working age.

Clinical Oct-17

Shared with service for

local learning and

improvements.

Audit of

identification of

carers and

assessment of

their needs in a

community

mental health

team

North Recovery

team

MH -

Community-

based mental

health

services for

adults of

working age.


Collaboration

with Primary

Care Clinicians

Service users

on CPA

Provider

wide








completed


audit



solution.

Record keeping

audit 2016/2017

Trust wide Provider

wide



staff on use of



relevant policy.

Audit of risk

assessments

2016/2017

Trust wide Provider

wide






in 2017/18.

Audit of risk

assessments

2017/2018

Trust wide Provider

wide


Audits of care

plans

Trust wide Provider

wide


2018


small scale audits.


teams.

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG43

Transition from

children’s to

adults’ services

for young

people using

health or social

care services

Trust wide Provider

wide







transitions

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG13

Workplace

health:

management

practices

Trust wide Provider

wide


2017



future

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG58

Coexisting

severe mental

illness and

substance

Trust wide Provider

wide


2017

Action plan under

development



completed


audit

misuse:

community

health and

social care

services

National audit of

psychosis

Adult acute

inpatient wards,

recovery team

and sort team

Multiple Clinical Data

collected

October

2017

Awaiting results

Cardio-

Metabolic

Assessment &

Treatments

Adult acute

inpatient wards,

recovery team

and sort team

Multiple Clinical Data

collected

February

2017

Agreed focus on physical

health reviews in

community settings.

The Community Enhancing Recovery Team was in the process of recruiting an assistant psychologist and researcher, part of whose role would involve looking into future audits at the service.


All services had a full range of specialists within the teams including psychiatrists, psychologists, nursing staff, recovery workers, support workers, occupational therapists, social workers, and other allied health professionals.

Staff were experienced, qualified and had the necessary skills to deliver effective care and treatment to meet the needs of their patients. In addition to mandatory training, staff could access specialist training for their individual role. Examples of specialist training undertaken by staff in the last 12 months included cognitive behaviour therapy, dialectical behaviour therapy, analytical therapy, substance misuse and psychosocial interventions. Staff were also able to attend lectures at local universities and colleges. Staff identified the training and development needs of staff during supervision and appraisal discussions and arranged for them to attend suitable training accordingly.

The service manager at the Mental Health Recovery Service North had been working at the service for three months at the time of our inspection visit. Prior to their establishment at the service, team meetings had not featured standard agenda items. The new service manager had introduced standing agenda items so the focus and structure of team meetings had greatly improved.

Managers provided new staff and agency staff with an appropriate induction. Staff were booked on training modules relevant to their role when they commenced their employment, shadowed experienced staff and completed mandatory training, which included health, and safety related modules. Managers monitored the new staff member’s progress in accordance with the trust’s probation procedures.

The trust had a performance management system in place, which included procedures for managers who needed to address poor staff performance.

There were no volunteers working at either of the services at the time of our inspection visit.

The trust’s target rate for appraisal compliance was 90%. As at February 2018, the overall appraisal rates for non-medical staff within this core service was 96%. At the time of the inspection, the appraisal rate for the Community Enhancing Recovery Team was 93%, Home Treatment Team 94% and the Mental Health Recovery Service North was 100%.




Team name

Total number of


staff requiring an

appraisal

Total number of

permanent non-

medical staff who


% appraisals

MH Recovery South 44 44 100%

North CMHT 2 2 100%

South East CMHT 4 4 100%

South West CMHT Admin 1 1 100%

West CMHT 1 1 100%

CERT 60 59 98%

Adult Home Treatment 36 34 94%

Early Intervention Service 34 32 94%

MH Recovery North 42 38 90%

South West CMHT 2 1 50%


Trust wide 1495 1440 96%



The rate of appraisal compliance for medical staff reported during this inspection was higher than


Team name

Total number of



Total number of

permanent medical

staff who have had

an appraisal

%

appraisals

Adult Home Treatment 1 1 100%

CERT 1 1 100%

Early Intervention Service 2 2 100%

MH Recovery North 2 2 100%

MH Recovery South 3 3 100%

South East CMHT Senior Medical 1 1 100%

North CMHT Senior Medical 1 0 0%



We looked at the appraisal rates for all staff at both services during our inspection and both services' rates were high. The appraisal rate for the Community Enhancing Recovery Team was 93%, Home Treatment Team 94% and the Mental Health Recovery Service North was 100%.

The trust’s target for clinical supervision is 66% for non-medical staff.


Between 1 March 2017 and 28 February 2018, the average rate across the two teams in this core service was 54%.

Caveat: there was no standard measure for clinical supervision and trusts collect the data in different ways, it is important to understand the data they provide.

The rate of clinical supervision reported during this inspection was lower than the 60% reported at


The trust’s target for clinical supervision for medical staff is 66%

Between 1 March 2017 and 28 February 2018, the average rate across all teams in this core service was 100%.


The rate of clinical supervision reported during this inspection was higher than the 60% reported at the last inspection.

Team name Clinical supervision

sessions required

Clinical

supervision

delivered

Clinical

supervision rate

(%)

MH Recovery South

2 2 100%



We looked at the compliance rates for the three services during our inspection. The compliance rates were low in all three services:

• 42% in the Home Treatment Team

• 48% in the Mental Health Recovery North Team

• 52% in the Community Enhancing Recovery Team

However, staff had access to additional supervision via ad-hoc one to one sessions with their managers and reflective practice sessions which were held three times a week. These additional supervisions were not formally recorded so we were unable to determine how many staff had taken advantage of them. The trust was only able to send limited supervision compliance data in relation to the Mental Health Recovery Service North as changes in the way the service recorded supervision had been recently implemented. For this reason, we have based the overall compliance rate for all three services for the January to April 2018 period to ensure each service has been treated equitably.


Multidisciplinary team meetings at both services were held regularly. Other regular meetings included case formulations, handovers and reflective practice meetings.

Staff shared information about patients during handover sessions at each service. For example, at the Mental Health Recovery Service North, the senior practitioner nurse carried out handovers to staff taking over patient responsibility when their usual care worker was commencing leave. Managers allocated daily tasks in relation to patient care in staff calendars.

We observed multidisciplinary team meetings at the Home Treatment Team and Community Enhancing Recovery Team and a daily meeting at the Community Enhancing Recovery Team. They were well attended from a range of disciplines, including nurses, doctors and a psychologist.


There was positive input from the whole team. Risk assessments and care plans were discussed and reviewed. There was strong evidence that the teams were providing an alternative service to those who would need a hospital stay and that disciplines had a good knowledge of their patients.

All services had effective links with external health organisations. Staff had been working with family care services and a local GP hub to increase awareness of each other’s needs and seek mutually beneficial ways of working together. Staff also reported that links with the police and adult social care organisations had improved over the last 12 months.


Practice

As of 28 February 2018, 100% of the workforce had received training in the Mental Health Act. The trust stated that this training is mandatory for all core services for inpatient and all community staff and renewed every three years.

There was a central team within the trust who staff could contact if they needed help and advice about the Mental Health Act. This team was also responsible for ensuring staff adhered to the Act and carried out audits of records to ensure staff followed best practice around the Act. The trust had a policy on the Mental Health Act, which reflected up to date guidance that staff could access via the trust intranet.

All services worked with detained patients who were due to be discharged to the community services or were on community treatment orders. The documentation relating to the Mental Health Act and use of community treatment orders was correct and up to date. Staff regularly reminded patients of their rights in ways they could understand and recorded this within patients’ care records. Patients had access to independent mental health advocacy services.

Care records referred to identified section 117 aftercare services where appropriate for patients who had been subject to section 3 or equivalent part 3 powers where appropriate. An example included reference to a patient who was receiving ongoing support from an occupational therapist following discharge.


As of 28 February 2018, 95% of the workforce had received training in the Mental Capacity Act Level 1 and 85% of the workforce had received training in Mental Capacity Act Level 2. The trust stated that this training was mandatory for all core services and renewed every three years.

However, staff at the Mental Health Recovery Service North were not up to date with their mandatory training in the Mental Capacity Act at the time of our inspection, as follows:

• 64% nursing staff had completed the Mental Capacity Act Level 1 training

• 76% nursing staff had completed the Mental Capacity Act Level 2 training

• 33% social workers had completed the Mental Capacity Act Level 2 training

The figures for all aspects of Mental Capacity Act training were high in relation to staff at the Community Enhancing Recovery Team and Home Treatment Team.

Despite some pockets of low compliance figures for the Mental Capacity Act training, staff at both services were adhering to the Act. Staff could give examples and explanations of different aspects the Act encompasses such as the use of capacity assessments, best interests decisions, Deprivation of Liberty Safeguards and the five statutory principles of the Act to demonstrate their knowledge and understanding. We saw evidence in care records that staff had undertaken capacity assessments, had involved professionals within and external to the team when appropriate, and had given patients help to make decisions on their own behalf. Patients had access to independent mental capacity advocacy services.

There was a central team within the trust who staff could contact if they needed help and advice about the Mental Capacity Act. This team was also responsible for ensuring staff adhered to the


Act and they carried out audits of records to ensure staff followed best practice around the Act. The trust had a policy on the Mental Capacity Act which staff could access via the trust’s intranet.




We spoke with nine patients and three carers during our inspection who all stated that staff within the three services treated them with kindness, dignity, respect, and compassion. They said that staff understood their individual needs, were interested in their wellbeing and helped them to understand and manage their own condition, care, and treatment. Staff supported patients to attend their chosen place of worship in the community and there were posters in the service’s reception areas about the trust’s chaplaincy service. Staff directed patients to other services where appropriate. For example, one patient had told staff they wanted help to lose weight so staff provided advice on healthy food choices and arranged for them to see a dietician. Patients also confirmed that they were confident that staff always maintained their confidentiality.

We accompanied staff members for two visits to patients’ homes to observe how each patient was treated. Staff interacted with the patients in a calm, polite and friendly manner and as they explained what was happening, they clarified their understanding about their current care and treatment.

We received feedback from 11 people who used the service via comments cards. Nine of these people commented that staff were kind and caring and felt their care and treatment needs were being met.

Staff who spoke with us said the trust actively encouraged them to raise concerns about any inappropriate treatment of patients or carers and there was an open culture around the protection of people who used its services.

Staff received information governance training which included the requirement to always maintain patient confidentiality.

Involvement in care


Staff involved patients in care planning in relation to their care and treatment and offered patients copies of their care plans. We looked at 24 patient care records across the three services and all but one of these contained evidence that patients were involved in decisions about their care and treatment plans.

We saw evidence that staff communicated with patients clearly, so they understood their care and treatment needs during visits to patients’ homes. The services used pictures, cue cards, easy read information and sought advice and guidance from speech and language therapists to help patients with communication issues. Staff also used online translation services if patients needed written information in different languages.

Staff involved patients in decisions about the service they received. For example, patients were able to be part of recruitment panels when new staff were being recruited to the services. The trust also ran a community patient forum group called Sunrise, which enabled patients to make suggestions on how to improve the service they received. The services also used Friends and Family Tests as a way of gaining feedback on the care and treatment they provided. The Community Enhancing Recovery Team had offered patients the opportunity to buy equipment up to the value of £750 to help with their care and treatment.

Staff assisted patients who wanted to make advance decisions about their care and treatment choices when requested. Staff also made patients aware of advocacy services through information leaflets and posters. We saw posters that gave contact details for advocacy services in the reception areas at each of the services we inspected.

Two comments cards contained negative feedback about the service the persons concerned had received. One included negative comments about the reconfiguration exercise, which had led to the person having to travel further for appointments using public transport. The other person


stated there was nothing good about the service they used but because the person did not provide their contact details or the name of the service they were using, we were unable to determine the reason for their being dissatisfied. Involvement of families and carers Staff involved families and carers appropriately in decisions about the care and treatment of the people they cared for and kept them informed. We saw evidence in patients’ care records that staff had consulted with families and carers about the care and treatment needs of the person they cared for and that carers assessments had taken place. Carers could ring the service during normal working hours or they could ring the first response team out of hours if they needed advice or support.

The services also used Friends and Family Tests as a way of gaining feedback on the care and treatment they provided.




We requested data from the trust in relation to the average waiting times for both services. The trust provided data for the average number of days from referrals to case allocation, which was two days and from when referrals were made to the services accepting them, which was eight days. The trust’s Single Point of Access team triaged referrals based on the individual needs and ensured the services dealt with urgent cases as a priority. An out of hours service was available if patients needed assistance during the night. The selection criteria for the Mental Health Recovery Service North was that patients were aged between 18 and 65, diagnosed with substantial and complex mental health needs, which primary care, secondary health care or social care services could not meet alone.

The criteria for the Community Enhancing Recovery Team was that patients were aged 18 or over at the time of referral, were living in Sheffield and under the responsibility of Sheffield care commissioning groups. The criteria for the Home Treatment Team was that adult patients were aged between 18 and 65, and patients aged between 16 and 17 years were experiencing their first episode of psychosis. It also cared for patients who were experiencing a relapse in their mental health, or were presenting with a first episode of acute mental health deterioration and needed treatment and/or additional intervention and who, without this, were likely to be admitted to hospital. The Mental Health Recovery Service North and Home Treatment Team receptionists took calls and care co-ordinators helped to identify how urgent calls were. The Community Enhancing Recovery Team’s telephone system was connected to an electronic call monitoring system so managers could monitor the number of calls received and identify any calls in queues, which staff needed to deal with. However, three people who completed comments cards stated they sometimes had difficulty getting through to the service they used by telephone. Any calls related to patients who were in crisis were referred to the trust’s Crisis Team. The services made attempts to engage with patients who were either reluctant to be involved with mental health care services or had been failing to attend their appointments. The multidisciplinary teams met to discuss and explore ways to encourage them to become engaged, for example other services that may be able to offer reassurance were contacted, agreements and increased flexibility with patients were negotiated in relation to their preferred times and locations for their appointments, and further discussions with the patient around their care planning and goals were held. The services rarely cancelled appointments and when it happened, staff gave patients a full explanation as to the reason why. The main reason for cancelling appointments was if a patient’s care worker was unexpectedly absent from work. If the patient needed a high level of support, an alternative care worker attended their appointment or the service contacted the trust’s enhanced support team. Appointments at the services usually ran on time. No patients we spoke with expressed any concerns about appointment times running behind and on the rare occasions they did, staff contacted them to explain why. The Community Enhancing Recovery Team contacted patients by phone or sent them text message reminders to alert them to any upcoming appointments. The Mental Health Recovery Service North previously had a similar arrangement in place but at the time of our inspection, the


text message service was faulty and the service acknowledged it needed to be rectified. The service did, however, contact patients by phone to remind them their appointment was due. The Home Treatment Team had small caseloads so staff could make daily contact with patients and visited people on the inpatient wards to identify those ready for discharge. The services supported patients during transfers and referrals to other services. Care workers accompanied patients when they attended appointments with other services upon request, offered patients reassurance and worked with other health professionals when necessary. As part of the 2016/17 NHS England standard contract, care organisations are required to use consistent clinical content headings when sharing discharge summaries. The transfer of care initiative aims to improve patient care by promoting and encouraging the use of professional and technical document standards. The services we inspected complied with the transfer of care initiative as staff used template letters for the discharge of patients from the service, which contained standard clinical content headings.


The clinic rooms at the Home Treatment Team and Community Enhancing Recovery Teams were of a reasonable size. However, the clinic room at the Mental Health Recovery North Team was too small. Patients who required a depot-injection were required to stand up for staff to administer these injections. While administering these injections standing up is not unusual, some patients prefer to receive them in a seated position. However, other rooms were fit for purpose at all three sites and included spacious reception areas with sufficient numbers of chairs that complied with infection control procedure and interview rooms with adequate soundproofing. At the Mental Health Recovery Service North, a flask of water and plastic cups were available in the reception area so patients could have a drink while they waited.


Patients we spoke with told us that staff at the services supported them in accessing education and work opportunities. Staff had supported a patient in accessing a course around building better opportunities and the service had helped them with an application for accommodation through a housing association. Staff had helped another patient to access courses in hair and beauty and mental health awareness, both of which resulted in the patient gaining recognised qualifications.

Staff encouraged patients to maintain contact with their families, friends and carers. Staff utilised charitable community services to help patients to maintain relationships and had a list of all the mental health charities in the Sheffield locality.

Staff encouraged patients who could not drive to access public transport as a way of travelling to and from the homes of those people who mattered to them and, where appropriate, reduced ongoing contact with patients to help promote their independence.


The services made adjustments for disabled patients and patients with specific communication needs. Each of the services had lifts, were wheelchair accessible with doors to the areas used by patients that opened automatically. The services used pictures and cue cards and sought advice and guidance from speech and language therapists to help communicate with patients with communication issues. Staff provided information in an easy read format for patients with a learning disability when required and had specific tools for communicating with patients on the autistic spectrum. Staff used online translation services if patients needed written information in different languages.

During our tour of the service buildings, we saw leaflets and posters, which included advice and

contact details in relation to:

• patients’ rights

• making complaints and giving feedback on the service


• health checks

• forced marriage

• chaplaincy service

• smoking cessation

• mother and baby wellbeing sessions

• credit unions

• safeguarding

• service user focus groups

• the Care Quality Commission.

Staff also routinely reminded patients of their rights during appointments.

Patients had access to signers and translators when required and staff could usually organise for them to attend to the needs of a patient with hearing impairment or for whom English was a second language within 48 hours. The services were also able to use a telephone translation line to help patients if needed.

The trust and Sheffield City Council were identified to work with a group of individuals to offer choice and control over their care through the provision of a personal health budget. The trust tasked the Community Enhancing Recovery Team with implementing the project which aimed to offer patients choice and control in their care by supporting each person to identify items that would improve their health. A budget of up to £150 was allocated for each patient and they worked alongside the staff team to formulate person centred plans. Examples of items that were purchased included bicycles, gym memberships, dialectical behavioural therapy workbooks, televisions and walking attire.


Whilst we observed patient leaflets on making complaints and giving feedback on the service, three out of the nine patients told us that staff had not provided them with information about how to make a complaint.

If complaints against staff members were of a serious nature, the services allocated an alternative staff member to the patient to prevent any anxiety on their part and to avoid any investigation being compromised. This also helped to mitigate the risk of the patient being discriminated against, harassed or unfairly treated by the person under investigation.

Staff handled complaints appropriately, as they were aware that there was an electronic form that they needed to complete if people who used the service wanted to complain and they knew to refer complaints to the service manager and the trust’s corporate affairs team that managed complaints.

Staff received feedback on lessons learned from investigating complaints during team meetings, supervision and appraisals and these were used to improve practice within the service. We saw evidence in minutes of team meetings that complaints and associated issues were a standing agenda item.

This core service received 94 complaints between 1 March 2017 and 28 February 2018. Eleven of these were upheld, 30 were partially upheld, 38 were not upheld and 13 were currently under investigation. There was one complaint referred to the Ombudsman of which was not upheld. The number of either partially or fully upheld complaints reported during this was lower than the 56 reported at the last inspection.


Team

name

Total

Complaints

Fully

upheld

Partially

upheld

Not

upheld

Referred to

Ombudsman

Upheld by

Ombudsman

Argyll

House 33 3 11 15 0 0

Wardsend

Road 13 3 7 3 1 0

East

Glade

Centre

11 0 2 7 0 0

Mental

Health

Recovery

Service

North

11 1 1 5 0 0

START 6 0 3 2 0 0

Limbrick

Centre 4 1 2 0 0 0

CERT 2 0 0 2 0 0

CRS 2 1 0 1 0 0

Firshill

Rise 2 0 0 1 0 0

Psychothe

rapy 2 1 0 1 0 0

SPA 2 1 0 0 0 0

CLDT 1 0 1 0 0 0

EDS 1 0 1 0 0 0

EWS 1 0 0 0 0 0

FDT 1 0 1 0 0 0

SORT 1 0 0 1 0 0

Street

Triage 1 0 1 0 0 0


February 2018, which accounted for 23% of all compliments received by the trust as a whole.



Leadership

Leaders had the skills, knowledge and experience to perform their roles. Some managers within the services had undertaken training to develop them as leaders and enhance their skills including managing sickness, management and leadership associated training and courses. Junior staff also confirmed they could access development around management and leadership.

The trust ensured managers had the skills, knowledge, experience and integrity to perform their roles. The trust’s recruitment process was thorough and job adverts contained essential people criteria.

Staff told us that senior managers were visible and approachable.

Vision and strategy

The trust’s vision was to improve the mental, physical and social wellbeing of the people in our communities and its values were respect, compassion, partnership, accountability, fairness and ambition. Staff knew and understood these and applied them in their day-to-day work. The trust had communicated the vision and values effectively to frontline staff as they were displayed in posters around the service buildings and in documentation and information used routinely by staff.

Staff we spoke with confirmed they had been involved in discussions about the strategy of the service they worked in although staff at the Mental Health Recovery Service North perceived consultation around the reconfiguration exercise had simply been a ‘going through the motions’ exercise, and that decisions had already been made by senior managers prior to speaking to them.

Staff could explain how they were working to deliver high quality care within the budgets available. For example, the Community Enhancing Recovery Team service manager explained that part of their team’s role was to provide intensive care and treatment to patients who lived in their own accommodation, at an annual cost of £50,000 a year per patient. The service manager stated if this provision was not available, the alternative could be that patients may need to be admitted to an inpatient setting at an annual cost of £300,000 per patient, six times the cost to the NHS for each patient.

Culture

Staff felt respected, supported, valued, and proud to work within the services they worked. However, three staff members working at the Mental Health Recovery Service North did not feel respected or valued by the wider trust. This was mainly due to the fact that they perceived that senior managers had a lack of regard for staff welfare and had poorly handled the reconfiguration of the community mental health services for adults of working age. Staff felt able to raise concerns without fear of retribution although recent changes in senior leadership meant some staff were wary due to not being familiar with their new senior managers’ management approach.

Staff knew how to use the trust’s whistleblowing procedures and could access them via the trust’s website. Staff also knew whom the trust’s freedom to speak up guardian was and what their role entailed in respect of supporting staff to speak out and raise concerns. We spoke with the service leads who confirmed staff had approached the guardian about their concerns over the reconfiguration exercise.

The trust had a performance management system in place, which included procedures for managers who needed to address poor staff performance. Staff confirmed that managers supported them if there were ever difficulties within their team.

Staff confirmed that appraisals included discussions about career development and support available for helping them with their career prospects.

The trust promoted equality and diversity in its day-to-day work and in providing career progression. The trust had equality and diversity policies in place, which were available to all staff


via the trust’s intranet. Discussions during staff supervision and appraisals focussed on issues around equality and diversity. Black, minority and ethnic staff within the services had raised concerns that patients and their carers had racially abused them. The trust had a zero-tolerance approach to racism and tried to work with people who used to service who had displayed racist behaviour to reduce the inappropriate behaviour. Staff devised interventions to tackle racism into patients’ care plans in a bid to address this issue but if attempts failed, the trust would allocate a different care worker to the patient. However, one staff member did state that the senior management team within the trust was not reflective of the diverse community as the majority of managers were white and British.

The sickness absence figures at the Mental Health Recovery Service North and Home Treatment Team were higher than the average for the provider. The trust average was eight per cent yet the average figure at the Mental Health Recovery Service North was 14% and the Home Treatment Team was 18%.

Staff had access to support for their own physical and emotional health needs. This included support from the trust’s workplace health and wellbeing group, smoking cessation support and an occupational health service.

The trust recognised staff success within the service. Staff had either received or been nominated for awards by their managers. Other teams within the trust had also praised the work undertaken by staff within the service.

During the reporting period, there were three cases where staff had been suspended, placed under supervision or moved to a different team.

Governance

There were inconsistencies with the effectiveness of the governance systems within the service. Some systems were effective, for example to monitor the progress of staff appraisals, the use of the Mental Health Act and Mental Capacity Act, to ensure lessons learned from complaints, incidents and safeguarding incidents were shared with staff and the services followed infection control prevention procedures. Other systems for monitoring staff supervision and mandatory training were ineffective as we identified low staff compliance in these areas across the three services we inspected. The governance of the medicines management arrangements at the Mental Health Recovery North Service had failed to address there being no system in place for the provision of emergency medication with the potential of placing people experiencing potentially life-threatening conditions such as anaphylaxis at serious risk. There were ineffective systems in place to ensure risk assessments were being regularly updated at the Mental Health Recovery North Service

Staff understood arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients. Staff worked with colleagues within the trust’s inpatient services and shared information with external partners through electronic systems, face-to-face meetings and e-mail.

There was a clear framework of what staff should discuss at meetings. The service leads confirmed that the teams they were responsible for used standard agenda items for meetings so all essential information was cascaded from managers to frontline staff.

Staff within the service participated in clinical audits and acted in response to these audit findings.

We saw evidence from minutes of clinical services leadership meetings that managers had an oversight of teams they managed. The minutes evidenced that safeguarding alerts, incidents, sickness levels, staff compliance with the Mental Health Act, physical health reviews and a wide range of other issues were being monitored and addressed where necessary. For example, at the Mental Health Recovery North Team, the need to ensure that all patients were being reminded of their rights under the Mental Health Act had been identified and the service manager had asked the trust’s Mental Health Act Team to facilitate a workshop around the obligations for staff under the Act.


We met with the service leads who had recently been appointed to their roles. They explained that the reconfiguration exercise had given them the opportunity to review governance structures. The key lines of enquiry used by the Care Quality Commission as part of its inspection process had been recently implemented to make the service’s governance structures more robust. The service leads were aware of high caseloads within the Mental Health Recovery North Team and confirmed that funding for an additional two care co-ordinators on a two-year fixed term contract had been secured.


Staff could discuss items for inclusion on their team’s risk register and that of the wider trust. Staff confirmed that their concerns were reflective of those contained within the risk registers.

The services we inspected had business continuity plans in place. These plans contained arrangements for emergencies such as adverse weather conditions, loss of information technology and premises, and outbreaks of flu.

The core service had recently undertaken a reconfiguration exercise to make efficiency savings and create a single point of access team where referrals were received and triaged. The single point of access team also worked with the trust’s acute and crisis services. The reconfiguration had also resulted in three different aspects of care being created; caseload management for stable patients who required less hands-on treatment, active care and intensive care for patients who required high levels of care or whose needs were particularly complex. Patients could step up and down from these three different levels of care when required.


The services collected data from other teams and directorates both within and outside the trust. Staff produced internal information from the trust’s electronic system. Staff confirmed the data was in a suitable format and not over-burdensome although one manager did indicate that because primary care services used totally different systems, there were occasionally issues with the quality of information received.

The services had access to sufficient information technology and equipment to do their work, which included mobile phones, tablets and laptop computers.

Information governance training was a mandatory requirement for staff within the trust. This training included the need to ensure that staff always maintained patient confidentiality.

The service managers used key performance indicators to monitor compliance in relation to mandatory training and other progress within their teams.

The services made notifications to external bodies as required. This included statutory notifications to the Care Quality Commission and safeguarding alerts to local safeguarding teams.

Engagement

Staff, patients and carers had access to up-to-date information about the services they used and wider trust through social media, emails, newsletters intranet and internet. Patients and staff were able to meet with members of the senior leadership team and governors to give their feedback and ideas for shaping the service.

The service enabled people to provide feedback in a variety of ways. People could complete questionnaires, attend feedback forums and participate in Friends and Families Tests. People could receive help in providing feedback to the services through local advocacy services.

The trust had engaged people who used the service and other stakeholders in the reconfiguration exercise during feedback sessions, presentations and drop in sessions.

Service leads confirmed that the trust had good relationships with patients, carers, commissioners, local authorities and other third-party organisations. At the time of our inspection, service leads were about to meet with a number of these stakeholders to discuss any ideas as to how the trust could help improve access to care.



Staff were given time to consider opportunities for improvements and innovation during team meetings, reflective practice sessions and during supervision and appraisal sessions.

Staff within the service had participated in national audits. These included audits relating to physical health, early interventions, medication, Prescribing Observatory for Mental Health and pharmacy.

The trust used the quality improvement methodology Microsystems which was developed by the Dartmouth Institute. This initiative enabled frontline staff to train as coaches and work with teams to help improve the quality and value of care they deliver to patients. They did this by understanding their systems and processes and redesigning care through testing small changes.


The trust confirmed that the Early Intervention in Psychosis Service had applied for accreditation from the Royal College of Psychiatrists and hoped to be accredited by September 2018.

The trust collaborated with the National Centre for Sports and Exercise Medicine in a project called move more for mental health to help people with mental illness to become more physically active in everyday life.


Wards for older people with mental health problems


Sheffield Health and Social Care NHS Foundation Trust provides wards for older people with

mental health problems over two sites. These were;

• G1 ward at Grenoside Grange Hospital – An 18 bedded mixed sex ward

• Dove dale ward at the Michael Carlisle Centre – An 18 bedded mixed sex ward


female, mixed)

Grenoside Grange Hospital G1 Ward 16 Mixed

Michael Carlisle Centre Dovedale Ward 18 Mixed





G1 was separated into two wards A and B three. Ward B had a garden in the centre and housed

male patients, as well as a self-contained flat, a seclusion room, lounges, along with staff training

rooms and the manager’s office. Ward A was connected to B via a staff only corridor, this ward

also had a garden at its centre and housed mainly female patients. The ward manager informed

us that if a bed was required for a patient they may be placed on a ward with patients of the

opposite sex due to bed numbers. In this case patients would be risk assessed to ensure this

placement was appropriate. Each ward had multiple lounges and dining areas as well as shower

and toilet facilities. The bedrooms at G1 were all en-suite and contained a sink and toilet. Some

en-suites also contained a shower. The ward was dementia friendly with furniture that contrasted

with the floor and there were dementia friendly signs on the doors. However, the handrails that

covered all of the ward did not markedly contrast with the colour of the walls. This could make it

difficult for patients to differentiate between the wall and the rail.

Dovedale ward consisted of one main corridor split into males at one end and females at the other.

The female corridor also housed a four-bedded female dormitory. The corridors were connected

by a central area which included the nurses’ hub and the clinic room. When you entered the ward,

it opened into the main lounge and dining area. There were separate lounges for male and female

patients. However; we found that the male lounge was over crowded with furniture and it would be

difficult for all male patients to congregate in the lounge at once.

Both services had a laundry room. Patients on Dovedale ward could use the laundry facilities to do

their own washing however; the area was small, untidy with paint peeling off the walls. We were

informed by the ward manager that the majority of relatives took patients’ clothes home to wash.

Both wards had outside areas available for patients to access. G1 had two central court yards

which were used by patients for growing vegetables and gardening. This area also contained a

shed where patients could sand and saw wood under staff supervision. There were also other

outdoor areas surrounding the site which were used by the service for outdoor events.

Dovedale ward had access to an outdoor area where patients could garden and grow vegetables

which were eaten on the ward. However, this area contained an old smoking shed which was

taped off for patients not to use as it was in disrepair. The path to the garden was slippy which

could be dangerous for patients.

Both wards had a variety of alarms to assist patients and staff. Both wards could provide call

bracelets to patient’s dependent upon their need. This was assessed individually. Both wards also

had access to bed and chair alarms for patients, which was also assessed on a patient by patient

basis. Nurse call alarms were available throughout Dovedale ward. G1 did have call buttons

however; we found that they were not easily visible and were located and varying heights on the

walls which meant they were not easily accessible to patients. We were informed this was

mitigated by patients having their own risk assessed alarms and staff observations, along with the

alarms having the ability to be detached and relocated if required.

Both ward areas were visibly clean and well maintained. Each ward was adequately furnished,

with the furniture of good standard and well maintained.


Over the 12 month period from 1 March 2017 to 28 February 2018 there were two mixed sex accommodation breaches within this core service.

Both incidents were due to gender mix and location of the bathroom facilities at the time of the incident. These breaches occurred on Dovedale ward. Work has since been undertaken on the layout of the ward and we found it was now compliant with the guidance on same sex accommodation.

Staff informed us that patients would be individually assessed if a bed was required for a member of the opposite sex. Following the assessments, patients on the ward could be moved to alternative rooms to ensure dignity and respect was maintained. We found that G1 ward at the time of inspection had a male patient between two female patient rooms, the ward manager informed us that the male and female had been assessed in regards to risk and there were no concerns with this patient.

There were ligature risks on both wards within this core service. All wards had a ligature risk assessment in the last 12 months.

One of the wards presented a high level of ligature risk due to the acuity of patients and remaining anchor points which included: door handles, ensuite doors, door corners, grab rails/mobility aids, beds, window restrictors, taps and flush handles.

The trust had taken the following actions to mitigate ligature risks: individual risk assessments, observations levels and the removal of items that may be used as ligatures. Work was underway to further reduce anchor points via programme of works to include door handle replacement, ensuite door replacement and a ward redesign.

For the most recent patient-led assessments of the care environment (PLACE) assessment (2017)

the locations scored higher than similar trusts for all four of the four aspects overall.


provided


appearance

and

maintenance

Dementia

friendly

Disability



people with mental

health problems

MH - Acute wards for


and psychiatric

intensive care units

MH - Other Specialist

Services

98%

97.3%

88.7%

91.6%

Grenoside Grange


people with mental

health problems

100%

98.2%

97.4%

100%

Trust overall 99% 97.8% 91.1% 91.8%


health and learning

disabilities)

98% 95.2% 84.8% 86.3%


We observed staff adhering to handwashing and infection control principles. Staff could describe

to us the infection control procedures in place for the various pieces of equipment that were used

by patients and staff.

Seclusion room

The seclusion room on G1 allowed for clear observation and two-way communication. The room

also had toilet facilities and a clock as well as windows to view natural daylight.

The windows were one way so the patient could look out but it was not possible to look into the

room from the exterior of the building, allowing for the patient’s privacy and dignity. There was no

way of observing the patients when in the bathroom so when not in use the bathroom was locked.

The bathroom was unlocked when patients required it. The Mental Health Act code of practice

states that seclusion rooms should have access to toilet and washing facilities, therefore the

seclusion room on G1 was in line with the code of practice.

Dovedale ward did not have a seclusion room however; they did have a newly refurbished

destimulation room which had the ability to adjust light colour and play music for patients. The

room was designed to be a quiet place to help calm patients. This room at the time of inspection

only had minimal furniture as the ward was looking to design the room in collaboration with

patients and staff. A patient who liked to frequent the room at the time of the inspection had

requested that there only be a mattress and pillow in the room.


We checked each clinic room at both sites; both were visibly clean and tidy. Room and fridge

temperatures on both wards were checked on a regular basis. The clinic room on Dovedale ward

had recently been refurbished this was due to the redesign of the ward to fit mixed-sex

accommodation guidelines. The ward manager informed the inspection team that the clinic room

was now larger and brighter and a better place to see patients. Resuscitation equipment on G1

ward was stored in the nurses office so it was accessible to staff. G1 ward had evidence that the

grab bag and emergency equipment was regularly checked. Dovedale did demonstrate regular

checks of the grab bag, emergency equipment, and machines. However, these records were

inconsistent, as we found gaps in recording.

Safe staffing

Nursing staff

Staffing levels were adequate to meet the needs of the patients on both wards. Staffing levels were established through the trust’s acuity system which took into account the number of patients and their individual risk needs. Each ward worked on a two shift basis with G1 having on average two qualified nurses and five support workers on the day shift and two qualified nurses and four support workers on the night shift. Dovedale’s staffing mix was slightly different with three qualified nurses and two support workers on the day shift and two qualified nurses and one support worker on the night shift. Managers were able to adjust staffing levels dependant on the acuity of the patients. When necessary, managers were able to use bank and agency staff to maintain safe staffing levels. Both wards aimed to


use regular bank staff as they were accustomed to the ward and the patients. The ward managers on G1 did feel that getting bank and agency staff at short notice was a struggle. In this situation the ward managers and deputy ward managers would fill the vacancy for the shift. Bank staff on both wards had access to the online system for patient records and were given a handover. Agency staff on Dovedale ward were given agency logins if they did not work regularly work on the ward they were accompanied by a support worker on shift. We did not see any evidence of leave or activities being cancelled due to staffing levels.

Definition






7.2 N/A


9% 13%





14% 5%


9% 5%





Number of vacancies nursing assistants (WTE*) At 31 March 2018 -5 N/A


Nursing assistant vacancy rate At 31 March 2018 -19% N/A

Bank and agency Use



February 2018 440 (8%) N/A


(Qualified Nurses)

1 March 2017 and 28




1 March 2017 and 28

February 2018 108 (2%) N/A



1 March 2017 and 28

February 2018 3716 (40%) N/A



1 March 2017 and 28

February 2018 899 (10%) N/A




1 March 2017 and 28

February 2018 270 (3%) N/A


This core service reported an overall vacancy rate of seven percent for registered nurses at 31

March 2018. We found that the vacancy levels during inspection were better than that recorded in the

provider information request ahead of the inspection; with the vacancy rate for qualified nurses for both

wards being 4.8 whole time equivalents.

This core service reported an overall vacancy rate of -19% for registered nursing assistants (minus numbers indicate an over establishment).

This core service reported a vacancy rate for all staff of three percent as of 31 March 2018.


Ward/Tea

m

Vacanc

ies

Establishme

nt

Vacan

cy rate

(%)

Vacanci

es

Establishme

nt

Vacan

cy rate

(%)

Vacanci

es

Establishme

nt

Vacan

cy rate

(%)

G1 Ward 3 16 19% -3 16 -19% -1 35 -3%

Dovedale 5 20 25% -2 10 -20% 3 43 7%

Core

service

total 8 36 22% -5 26 -19% 2 78 3%

Trust

total 32 433 7% 15 353 4% 68 1339 5%


Between 1 March 2017 and 28 February 2018, bank staff filled eight percent of shifts to cover sickness, absence or vacancy for qualified nurses.

In the same period, agency staff covered one percent of shifts for qualified nurses. Two percent of shifts were unable to be filled by either bank or agency staff.


staff

Shifts filled by

agency staff



Dovedale

Ward 2666 46 (2%) 9 (<1%) 64 (2%)

G1 Ward 2700 394 (15%) 24 (1%) 44 (2%)

Core service

total 5366 440 (8%) 33 (1%) 108 (2%)

Trust Total 32,394 4977

(15%)

7252

(22%)

900

(3%)



In the same time period, agency staff covered 10% of shifts for nursing assistants. Three percent of shifts were unable to be filled by either bank or agency staff.


staff

Shifts filled by

agency staff


or agency staff


Dovedale

Ward 3222 629 (20%) 616 (19%) 125 (4%)

G1 Ward 6137 3087 (50%) 283 (5%) 145 (2%)

Core service

total 9359 3716 (40%) 899 (10%) 270 (3%)


(37%)

5623

(9%)

1760

(3%)


This core service had 7.2 (9%) staff leavers between 1 March 2017 and 28 February 2018. This was lower than the 12.2% reported at the last inspection (November 2016).



G1 Ward 34.7 4.6 12%

Dovedale 40.8 2.6 6%


Trust Total 1351.6 129.6 8%

The sickness rate for this core service was nine percent between 1 February 2017 and 31 January 2018.


(at latest month)



Dovedale 18% 10%

G1 Ward 9% 9%


Trust Total 8% 7%


Dovedale ward had a fill rate of over 125% for care staff for all day and night shifts.

Key:

> 125% < 90%

N-nurses

C- care staff



Medical staff

There was adequate medical cover on both wards, with two consultants and a junior doctor

covering Dovedale ward. G1 ward had a consultant along with a clinical fellow. Out of hours cover

was provided by an on-call rota. In a medical emergency, the policy on each ward was to contact

the emergency services.

Mandatory training

The compliance for mandatory and statutory training courses at 28 February 2018 was 94%. Of the training courses listed one failed to achieve the trust target and just failed to score above 75% at 74%.

Key:








Level 1 100%

80% 87%



Falls) 99%

80% 97%













Dignity standards) 90%

80% 85%





N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

N

%

C

%

November 2017 December 2017 January 2018 February 2018 Dovedal

e 94.6 162.

1

78.

3

226.

7

75.4 164 76.

1

206.

5

68 186.

6

72.

7

222,

6

69.

2

198 69.

6

261.

2

G1 106.

7

98.7 83.

7

108.

4

112.

4

95.

7

95.

3

121.

5

109.

9

102.

2

79.

3

133.

9

73.

2

103.

4

79.

9

114.

2




Level 0 74% 80% 80%


Overall; staff in this service had completed all modules of mandatory training set by the trust however; deprivation of liberty safeguards training was below the trust target at 74%. All staff we spoke to stated they were up to date with their mandatory training. Staff on Dovedale ward told us they had not had as much time for training recently due to recent building work on the ward.



All of the eight patient records reviewed had an up to date risk assessment for each patient. Upon

admission each patient had a detailed risk assessment and management plan, this is a recognised

risk assessment tool known as DRAM. Risk assessments were started in the community before

the patient was admitted to the ward and were completed in conjunction with patients and carers.

Falls risk assessments would be carried out if it was highlighted in the detailed risk assessment.

Risk assessments were updated regularly and were assessed at the twice weekly multidisciplinary

team meetings.


Staff were aware of patients’ individual risks. These could be accessed through the patient’s notes

and were discussed in handovers. Risk assessments were reviewed at the multidisciplinary team

meeting each week and updated where appropriate. We saw evidence of patients’ specific risks

being addressed, for example a patient susceptible to falls had been given hip protectors.

Staff informed us that if they thought a patient was at risk they would search the patient and room.

Both wards adhered to the trust search policy and had a list of banned items.

Staff were able to respond to the changing risks of patients, for example we saw evidence of a

patient’s risk of falls reducing while on the ward.

Staff adhered to best practice when implementing a smoke free policy where practicable. G1 was

a smoke free ward but due to the nature of the patients they cared for, some patients were

sometimes not able to remember they had given up smoking. In these cases; the staff would work

with the patient and carers to carry out interventions and if needed to facilitate smoking in a safe

way. Dovedale had a smoking shelter in the garden that was not in use.

Informal patients were able to leave the wards at will; notices were visible throughout the wards

informing patients if they wished to leave they should ask staff to open the doors for them.


This core service had 46 incidents of restraint (on 32 different patients) and 22 incidents of

seclusion between 1 March 2017 and 28 February 2018.

Over the 12 months, there was an increase in the incidence of restraint in January 2018 where

there were 10.



2018.


restrained


prone restraint

Rapid

tranquilisations

G1 ward 22 24 19 0 (0%) 0 (0%)

Dovedale

ward 0 22 13 0 (0%) 6 (27%)

Core service

total 22 46 32 0 (0%) 6 (13%)

Staff on Dovedale ward informed us that they used rapid tranquilisation as a last resort. Rapid tranquilisation was reported on the incident system by staff when it occurred and physical health monitoring took place following incidents of rapid tranquilisation. As per the trust policy, staff attempted de-escalation strategies which included the use of ‘as required’ medication, in line with National Institute for Health and Care Excellence guidelines. Patient medication charts included information on when ‘as required’ medication should be used, the minimum time between uses if the first dose of medication had not worked and information on the patients’ care plan.

There were six incidents of rapid tranquilisation which accounted for 13% of the restraint incidents.

There have been zero instances of mechanical restraint over the reporting period.

The number of restraint incidents reported during this inspection was lower than the 55 reported at the time of the last inspection.

Staff on both wards had received RESPECT training, this training provided staff with the skills to de-escalate situations without using methods of restraint.

Over the 12 months, the use of seclusion fluctuated. Instances of seclusion ranged from zero to six per month during this time.

The ward manager on G1 at the time of the inspection said the spikes in seclusion on August 2017 and January 2018 were related to one patient in August and two patients in January. Staff on G1

3

7

0

6

10

1

3

6

3

10

6

0 0 0 0 0 0 0 0 0 0 0 00

2

4

6

8

10

12


Total restraints over the 12 month period

Number of incidents of the use of restraints

Number of prone restraints

Number of mechnical restraints

Number of incidents resulting in the use of rapid tranquilisation


ward explained that in many cases they would not use seclusion as they would sit and speak with patients in a quieter room which they found proved effective in calming them down.

There have been no instances of long term segregation over the 12 month reporting period.

Safeguarding

Staff received training in safeguarding. At the time of the inspection 95% of staff had attended safeguarding children level 2 and 95% safeguarding adults level 2. All staff on the wards had attended safeguarding children level 3. Staff we spoke to had a good understanding of what safeguarding was and were confident in raising safeguarding concerns. The wards had specific guidelines for children visiting the ward. For example; G1 stopped any children under the age of 12 visiting the wards due to a previous near miss incident. Relatives were informed that any child under the age of 12 would have to visit with their relative in the café area in front of the ward, if this was not deemed suitable for the patient the ward would request that the children did not attend visits.




Sheffield Health and Social Care NHS Foundation Trust submitted no serious case reviews commenced or published in the last 12 months [1 March 2017 and 28 February 2018] that relate to this core service.

1

0 0 0

2

6

3

0

2

0

5

3

0

1

2

3

4

5

6

7


Total seclusions over the 12 month period

Number of incidents of the use of seclusion



All records were electronic including patient records and medication charts. All staff had access to

the online system including bank staff. Dovedale ward provided temporary system logins for

agency staff who attended the ward. G1 ward printed information for agency nurses as they did

not have separate logins. All 1:1 observations that were hand written were scanned into the

system.


We reviewed eight prescription charts and found no concerns. All medicines on the wards were managed through the electronic system. For agency staff not able to access this system, there were pictures of the patients with the medication so staff were able to identify the patients’ correct medication. Staff followed good practice in relation to the dispensing and administration of medication. We observed staff using the antipsychotic checklist for medication before and during the issuing of medication to patients. Patients’ physical health was monitored if they were prescribed an antipsychotic medication. G1 ward used the neuropsychiatric inventory tool, this is an assessment of psychopathology for patients with dementia.


Providers must report all serious incidents to the strategic information executive system within two working days of an incident being identified.

Between 1 March 2017 and 28 February 2018 there were no incidents reported by this core service. A ‘never event’ is classified as a wholly preventable serious incident that should not happen if the available preventative measures are in place. This core service reported no never events during this reporting period.

We asked the trust to provide us with the number of serious incidents from the past 12 months. The number of the most severe incidents recorded by the trust incident reporting system was broadly comparable with the strategic information executive system.

The number of serious incidents reported during this inspection was the same as the number reported at the last inspection.


All staff knew how to record an incident and what should be recorded. Incidents were recorded through the trust electronic system and all incidents went to a ward manager to review. Once these incidents were reviewed by the ward manager they were sent to the senior operational managers for review further if required. All incidents were reviewed at the quarterly governance meeting. Learning from incidents was fed back to staff at team meetings and handovers. G1 ward had adjusted their policy around children visiting the ward due to a near miss incident with a young child. Staff were aware of duty of candour and were open and transparent when things went wrong. Staff on G1 ward provided examples of facilitating multiple meetings with a family due to the family wishing to be informed more frequently about the care their relative was receiving.


Ward managers informed us that following a serious incident, staff would receive debrief along with patients and psychological support would be offered if required.


In the last two years, there have been no ‘prevention of future death’ reports sent to Sheffield Health and Social Care NHS Foundation Trust.




We reviewed eight care records during our inspection. All records contained a care plan and risk assessment that was created following admission. Each patient had received a physical health check upon admission, however one patient had refused a physical check. This refusal was noted in the patient records each time a physical health assessment was attempted. Each patient received a comprehensive detailed risk assessment and management plan on admission; this was completed with involvement from the psychologist liaison and relatives and/or carers. The risk assessments were assessed each week at the multidisciplinary team meeting and were updated as necessary. Care plans were formulated with the involvement of the patients, relatives and /or careers and the nursing teams. All of the care plans we reviewed showed evidence of patient involvement, were personalised, holistic and focused on the patient’s recovery.


The ward staff on G1 utilised therapy dolls for patients and found this very effective however; staff noted that family members could find this distressing, therefore they would explain the use of the therapy dolls and the effect it was having on their relative. G1 ward also had the use of Paro seals, Paro seals are therapeutic interactive robots baby seals that are used for patients with dementia and other cognitive disorders. Staff found the seals to be very effective as they brought back patients memories of having birds and various other pets. The ward also used numerous memorabilia items to help patients. They had used a world war two uniform along with other memorabilia from the era such as soap and toys. G1 ward had also used pet therapy on the ward; they used miniature horses for an Ascot themed day and also had visits from a local dog handler. Both wards ensured patients had access to physical health care, in many cases the wards facilitated patients going to their regular opticians and dentists where possible. Each ward had access to a dietician who assessed patients’ dietary needs. Patients on both wards were encouraged to live healthier lives with the meals they chose and smoking cessation was offered. Staff acknowledged that patients may not be aware that they had ceased smoking and would offer alternatives. G1 ward utilised the Neuropsychiatric Inventory tool for patients. The Neuropsychiatric Inventory tool is

a tool used to measure patient outcomes. The use of the tool had been reviewed by a junior doctor

who had presented their findings nationally.




completed


audit

QS86 Falls in

older people

Older-adult

inpatient

settings

MH - Wards

for older

people with

mental health

problems

Clinical Apr-17 Regular Falls audits to be

undertaken

Mental

wellbeing and

independence

for older people

(QS137)

Dovedale Ward

MH - Wards

for older

people with

mental health

problems



Collaboration

with Primary

Care Clinicians

Service users

on CPA

Provider

wide








solution.

Record keeping

audit 2016/2017

Trust wide Provider

wide



staff on use of



relevant policy.

Audit of risk

assessments

2016/2017

Trust wide Provider

wide






in 2017/18.

Audit of risk

assessments

2017/2018

Trust wide Provider

wide


Audits of care

plans

Trust wide Provider

wide


2018


small scale audits.


teams.

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG43

Transition from

children’s to

adults’ services

for young

people using

health or social

care services

Trust wide Provider

wide







transitions

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG13

Workplace

health:

management

practices

Trust wide Provider

wide


2017



future

Assessment of

National

Institute for

Health and Care

Excellence

Guidance: NG58

Coexisting

Trust wide Provider

wide


2017

Action plan under

development


severe mental

illness and

substance

misuse:

community

health and

social care

services


Both wards had access to consultants, junior doctors, occupational therapists, speech and language therapists, psychologists, psychiatrists, dieticians and pharmacists. Staff were able to refer to the local authority for the assistance of social workers. All off the staff who worked on the wards were knowledgeable and skilled in their field of work.

Volunteers were recruited and trained centrally by the trust; if the wards wished to have a volunteer they could request this centrally.

The trust’s target rate for appraisal compliance was 90%. As at February 2018, the overall

appraisal rates for non-medical staff within this core service was 99%.



Ward name

Total number of


staff requiring an

appraisal

Total number of

permanent non-

medical staff who


% appraisals

G1 40 40 100%

Dovedale 43 44 98%


Trust wide 1495 1440 96%

The trust’s target rate for appraisal compliance was 90%. As at February 2018, the overall


The rate of appraisal compliance for medical staff reported during this inspection was the same as


Ward name

Total number of



Total number of

permanent medical

staff who have had

an appraisal

%

appraisals

Dovedale 2 2 100%

G1 1 1 100%




The trust’s target for clinical supervision was 66%.

Between 1 March 2017 and 28 February 2018 the rate across both teams in this core service was 50%.

Caveat: there is no standard measure for clinical supervision and trusts collect the data in different ways, it’s important to understand the data they provide.


sessions required

Clinical

supervision

sessions delivered

Clinical

supervision rate

(%)

Dovedale 196 100 51%

G1 Ward 167 80 48%



Both ward managers acknowledged that supervision was low on the wards. Each staff member should receive two supervisions per quarter. Staff had received at least one supervision in each quarter. We were informed by ward managers and senior operational managers that the low level of supervision was due to demands on staff on the ward. The senior operational managers and ward managers felt that there were activities they did with staff that could be counted toward supervision but did not fit in with the model. This included discussions in meeting around changes in guidance and discussions around specific areas of patient’s needs. Senior operational managers for the ward acknowledged the low levels of supervision and had started to place extra staff on the wards so supervision could be accomplished. The trust was in the process of changing the way supervision was recorded to include electronic recording to ensure it could be more effectively monitored. Staff we spoke to felt that there were receiving a good level of supervision and felt supported by the management team.


Multidisciplinary team meetings were held twice a week on both wards. These meetings included consultants, psychiatrist, ward manager, discharge co-ordinator, senior occupational therapist and a nurse. Other parties were invited to the meeting depending on the needs of the patient. We observed a multidisciplinary team meeting while during our inspection. We found that the meeting explored the clinical, social, emotional and psychological needs of the patient and was very patient focused. The patient’s relative attended the meeting and the team clearly explained the patients care to relatives and discussed their ideas and concerns raised. Ward handovers included information on the patients currently being treated on the wards. We observed a handover where the staff discussed patients’ risk assessments, the activities that would take place during the shift along with an update from the multidisciplinary team meeting. Both wards had effective working relationships with the discharge teams and social services.


Practice


As of 28 February 2018, 97% of the workforce in this core service had received training in the Mental Health Act. The trust stated that this training was mandatory for all core services for inpatient and all community staff and renewed every three years.


Staff we spoke to had a good understanding of the Mental Health Act and its guiding principles. Support workers informed us that they were regularly informed about each patients’ section 17 leave. A Mental Health Act administrator was available to staff if they required support. The trust policies and procedures for the Mental Health Act were available on the electronic system for all staff. Both wards undertook a weekly audit of the Mental Health Act to ensure that all patient records were up to date. Patients who were detained under the Mental Health Act had access to an independent mental health advocate, staff knew how to refer patients to this service and information was displayed around each ward. Patients’ rights were read to them in a way that they understood. Ward managers noted that if a patient had not understood their rights, this was documented on the patient’s care record and further attempts to communicate the patient’s rights would be made. Each ward had displayed information for informal patients informing them they could leave the ward at any time, as both wards were locked patients could request that staff opened the doors for them if they wished to leave.


Staff we spoke to had a good understanding of the Mental Capacity Act, including the deprivation of liberty safeguards. Staff were aware of the policy and informed us that it could be found on the electronic system for them to access. We saw evidence of patient’s mental capacity being assessed in their medical records. Patients files were audited in relation to Mental Capacity Act each week to ensure compliance with the Act.

As of 28 February 2018, 96% of the workforce in this core service had received training in the Mental Capacity Act. The trust stated that this training was mandatory for all core services for inpatient and all community staff and renewed every three years.

The training compliance reported during this inspection was higher than reported at the last inspection. G1 ward reported training compliance of 95% at the last inspection and Dovedale reported 25%

The trust told us that two deprivation of liberty safeguard applications were made to the local authority for this core service between 1 March 2017 and 28 February 2018. CQC received no direct notifications from the trust between 1 March 2017 and 28 February 2018. The trust policy for deprivation of liberty safeguards stated that wards managers were responsible for notifying CQC once the outcome of the application has been received. Upon reviewing the evidence we can see that a notification was submitted to CQC regarding a deprivation of liberty safeguard application. The number of deprivation of liberty safeguards applications made during this inspection was lower than the nine reported at the last inspection.




We observed staff interacting with patients while on the ward, these interactions were respectful and responsive. Whilst observing meal times on the ward, we saw staff treating patients with dignity and respect. Patients were supported to eat meals when required. Staff on G1 ward shared the meal times with patients and engaged with the patients while they ate. On Dovedale ward we observed that interactions with patients and staff were limited, for example staff did not ask patients if they were enjoying their meal or if there was enough food. Both wards actively encouraged patient involvement in their care. This was evidenced in the risk assessment and care plans for each patient which reflected their individual needs. All patients and carers we spoke to had positive things to say about the care they or their relative was receiving. Carers we spoke to on G1 ward felt that they had learnt more about dementia while their relative was on the ward which allowed them to understand the condition and the treatment their relative was receiving. Staff understood the individual needs of patients including their personal, cultural, social and religious needs. G1 had a patient whose relative loved to cook for the ward and they would regularly bring in food related to their cultural heritage. The ward welcomed and celebrated this by having an Indian themed day. Patients got involved by building a Taj Mahal with the occupational therapist and enjoying Indian food. G1 hosted multiple themed events, during the inspection they had a pub themed day with a bar and live piano music with pie and peas for lunch.

The 2016 Patient-led assessments of the care environment score for privacy, dignity and wellbeing at both core service locations scored higher than similar organisations.


and wellbeing






problems.

94.3%

Grenoside MH - Wards for older people with mental health

problems 100%

Trust overall 96.6%


and learning disabilities) 90.6%

Involvement in care


On admission to the ward, patients were shown round and given a welcome pack with information about the ward. Patients’ family and/or carers could be invited to join the induction to the ward. All patients, where possible, were included in their risk assessment and care plan and we found evidence of this in the care records we reviewed. Staff told us that they also invited families and/or


carers to be involved in developing patients care plans and risk assessments. Families were able to provide information such as the patients likes, dislikes, preferences and their routine. Support workers on the ward supported the patient and their family to fill out the ‘this is me’ booklet to get to know the patient. G1 ward had adapted its outdoor space to fit the likes of the patients on the ward for example: they had added a shed as some patients had feedback that they were used to being occupied with woodwork. This shed allowed patients to sand, saw and paint bits of wood. Access to the shed was available to all patients with supervision required. Patients also had access to the garden to grow fruit and vegetables which were then used in the ward food. Staff told us that this brought a sense of achievement to many of the patients. Patients were actively encouraged to give feedback on the care they received. Staff supported patients to complete comment cards if they wished to make a comment. Patients had access to independent mental health advocates; information about this was available for patients on the ward.


Staff encouraged the involvement of families and carers where they could, this included getting them involved in the care plan and risk assessments. The wards also provided psychological support to families and careers if they required it which was provided by the onsite psychologist. G1 ward had a carers meeting available for family and carers to attend, the sessions included activities and provided a place to talk to other carers. The ward also conducted themed meetings depending on the needs of the carers. Dovedale did have a carers meeting but they stated that it was not well attended. Ward staff at G1 also encouraged friends and relatives to join them for activities and themed days, this included events such an Ascot day where miniature ponies visited the ward. Families and carers were actively invited to give feedback on the service their families were receiving through comment cards and directly to staff.




Bed management

The trust provided information regarding average bed occupancies for four wards in this core service between 1 March 2017 and 28 February 2018.



Dovedale 96.95 – 107.22

G1 Ward 65.4 – 101.25


We are unable to compare the average bed occupancy data to the previous inspection due to differences in the way we asked for the data and the time period that was covered.



Dovedale 42.33 – 188.57

G1 Ward 67 - 147

This core service reported no out area placements between 1 March 2017 and 28 February 2018.

This core service reported no readmissions within 28 days between 1 March 2017 and 28 February 2018.


Between 1 March 2017 and 28 February 2018 there were 115 discharges within this core service. This amounts to 14% of the total discharges from the trust overall (804).

There were 91 delayed discharges between 1 March 2017 and 28 February 2018, all of which were on G1 ward.

The ward manager at G1 explained that at the time of the inspection, five patients’ discharges were delayed due to funding not being agreed. They also informed us that patients could be delayed as relatives had not been able to find somewhere suitable for the patient. In the past the ward had gone with relatives to help them pick a new residency for their family member.

The patients discharge journey from both wards commenced at the time of admission. Patients potential discharge dates and recovery were discussed in the multidisciplinary team meetings. Both wards worked closely with the discharge teams and social services to ensure that patients were discharged smoothly. Referral to assessment and treatment times was not provided for this service.



Both wards provided patients with their own private rooms, except for Dovedale ward which had one female dormitory for up to four patients. Patients were able to personalise their rooms if they wished however; this was done on a case by case basis depending on the patients’ risks. All patients had access to lockable safes in their rooms to secure their possessions. Patients on each ward were able to have a key to their own room however; this was individually risk assessed in regard to whether they could use the key and if they wanted a key to their room. Staff and patients had access to therapy rooms, a clinic room, dining room and multiple lounges throughout the services. Dovedale ward had access to an indoor gym on site for patients to use. Patients were able to meet visitors on the ward in the lounge areas and in a separate coffee area on G1 ward. Patients were able to make personal calls in private and G1 ward had facilitated skype calls for patient who had relatives in other countries. Both wards enabled patients to access outdoor space and each ward had gardening facilities where patients would grow their own fruit and vegetables. G1 had multiple outdoor spaces which were used for gardening, they also had a shed where patients could sand and chop wood if they wished.

The 2016 Patient-led assessments of the care environment score for ward food at the Michael Carlisle centre scored higher than similar trusts. Grenoside scored lower when compared to other similar trusts for ward food.


Michael Carlisle MH - Acute wards for adults of working age and




problems.

97.5%

Grenoside MH - Wards for older people with mental health

problems.

88.9%

Trust overall 96.4%



Patients were supported to maintain contract with their families and careers. We were informed that one patient was unable to remember when a family member had visited and would get upset that they were not seeing family. The ward decided to film the visits and show the patient when they became upset.



Both wards were enabled externally for disabled access. Each ward layout lent itself to disabled access and had disabled toilet facilities. Each ward also had a hearing loop system. Staff were able to provide documentation in other languages and easy read format for patients if they required it, this was available through the trust intranet system. Staff had access to an interpreter system and could request signing assistance if required. There was a variety of food choices available to meet specific dietary requirements. All food at G1 ward was cooked on site. The ward had a relationship with a local pub that served vegan meals which allowed them to cater to these specific needs if required. Dovedale wards food was not cooked on the ward, however there was a range of food to choose from that took into account patients dietary and religious needs. Both wards had access to spiritual support with various chaplins of different denominations. Dovedale ward had links with local churches to allow patients to attend their own church if they desired. The Chaplin on G1 ward visited regularly and joined in with activities on the ward.


Patients and carers received a brochure about the ward at admission. This included key information about the ward including how to complain or raise concerns. The patient and carers we spoke to were aware of how to make a complaint. This core service received no complaints between 1 March 2017 and 28 February 2018.

This core service received 221 compliments during the last 12 months from 1 March 2017 to 28




Leadership

Each ward had an experienced ward manager who was registered professional nurses, each had

been with the trust for a number of years.

Ward managers had a passion for the service they were delivering and could clearly explain how

their teams were working to provide high quality care.

Development and leadership opportunities were widely available to the ward managers and staff.

We saw examples of domestic staff on the ward having RESPECT training and leading on

infection prevention control audits. Ward managers were actively involved in projects outside of

the ward. The ward manager on Dovedale was working with the trust to help design and develop

the new ward that was in development. They actively encouraged all staff to attend the feedback

meetings and give their opinion. The ward manager on G1 regularly attended and spoke at

national conferences and due to this the ward had been able to procure samples of new

technology to assist in their patient’s recovery.

Vision and strategy

Most staff we spoke to could tell us the trust values. These values were incorporated into each wards vison and values which had been put together with collaboration from staff and patients. Ward values were in line with the trust’s vision and values. Staff involvement in discussions about changes to the service was actively encouraged. This was seen with the development of the new site for Dovedale ward, the ward manager and all staff members had been encouraged to attend meetings and feedback sessions on the design of the new ward. Staff had also had the chance to look at the blue prints for the new design and give feedback. Staff informed us of the variety of different work they were involved in to help deliver high quality care. G1 ward had applied for a local grant to help develop the outside space for patients and staff also participated in the local art show every year that were displayed around the city. Both ward managers reported they received a good level of support from their senior operation managers in relation to maintaining high-quality care.

Culture

All staff we spoke to across each ward felt respected, supported and valued by their team and

managers. Staff told us that they enjoyed coming to work and felt very supported by the ward. We

observed positive staff interactions with managers while touring the wards. The culture across

both wards was a very positive one with staff feeling like they could raise concerns and contribute

to the ward.

Staff were aware of the whistle-blowing policy but informed us that they have never had to use it.

Many staff told us that if they had concerns they felt comfortable raising them with the

management team directly.

Psychological support was offered to staff for a variety of reasons, a staff member reported they

had been strained due to the acuity of patients and psychological support was offered. A staff


member with personal difficulties had also been offered psychological support. This was offered

through occupational health but also on the ward by the team members.

Staff sickness rates for this service were higher than the overall trust average, especially on Dovedale ward. The ward manger advised that a large amount of this sickness was due to long term sickness of staff such as bereavement and physical health issues. Staff files demonstrated staff being supported back into work following sickness.

During the reporting period, there were no cases where staff had been either suspended, placed under supervision or were moved to a different ward.


Governance

Mandatory training was above the trust target of 80% except for the training on deprivation of liberty safeguarding which as was 74%. Managers on each ward monitored the staff training compliance through an electronic system. We also found that ward managers kept their own working spreadsheet to highlight which modules were due for renewal. Managers could monitor staff appraisal and supervision compliance, both ward managers and senior operations managers were aware of the low levels of supervision and had plans in place to help improve the level of compliance. These included the use of a central electronic recording system of supervisions and bringing in extra staff so the supervisions could be completed. Staff would receive supervision once a quarter and were happy with the supervision received. Quarterly governance meetings were held across both wards which all staff could attend if they wished. The meeting discussed incidents, and the risk register. Ward managers across each ward had regular contact to discuss the individual wards and support each other. Wards held team meetings where key learning from incidents would be fed back. Staff had a good understanding of the Mental Health Act and Mental Capacity Act. A central Mental Health Act administrator helped monitor staff compliance and provided advice and guidance to staff when required. Staff undertook and participated in local audits on the wards, certain staff were leads for specific audits, for example the head housekeeper was the lead for the infection prevention control audits. Audits were cross checked by ward managers from other areas to ensure compliance.

Staff had a clear understanding of the arrangements for working with other teams, both within the provider and externally to meet the needs of the patients.


The ward manager had access to the ward risk register and was able to update the risks when appropriate. The risk register was reviewed at the quarterly governance meeting and with other ward managers across the service. Feedback from the risk register was also addressed within team meetings. Risks were escalated through this process.


Staff had access to the equipment and information required to do their job. All care records were stored electronically for staff to access. There were adequate devices on site for staff to access


information electronically. Staff on Dovedale ward recorded all observations on the ward thorough tablet devices. Ward managers at both sites had access to the central system which allowed them to access information pertinent to their role. This included patient data, staff performance data as well as information on discharges and other key performance indicators. Each ward also had spreadsheets for collating and keeping up to date with staff training and supervision.

Engagement

Staff were kept up to date with information from the trust through the intranet and bulletins as well as

team meetings and handovers.

Staff on both wards actively encouraged feedback from patients and carers. This was done by collating

exit questionnaires and encouraging patients and carers to fill out comment cards on the wards.

Patients feedback that they had felt uncomfortable as visitors had been on the ward while they were

getting ready for bed. Due to these comments G1 ward had adjusted visiting hours on the ward to

prevent this.

The trust had a public facing website which could be accessed by the public which provided

information on the trust including details on the services provided and news from the trust.



The wards did not participate in any national accreditation schemes.

Staff were given the time to speak at conferences and other organisations to relay best practice, this included the occupational therapist and the ward manager on G1 ward. There was evidence that the service was working with external organisations to help provide innovative care. The service used Paro seals as well as other distraction techniques. The ward manager for G1 had secured virtual reality devices to use with patients through external work. G1 ward had recently been assessed by positive practice in relation to their dementia environment. At the time of the inspection the results of this assessment was not known. Representatives from the trust presented at the international dementia congress in November 2017 on the subject of dementia and antipsychotic medication. G1 ward held an arts exhibition for patients to display and enjoy art.

sheffield health and social care nhs foundation …...2018/10/05 · sheffield health and social...

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