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Inspection report

Date of Inspection: 11 January 2011
Date of Publication: 9 February 2011
Inspection Report published 9 February 2011 PDF

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People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

Our judgement

We found that the location is not meeting this outcome on the acute mental health wards. We were concerned that there was no robust systematic process of individualised risk assessment which is based on a nationally recognised evidence based tool for mental health. We found that the patient’s risk assessment process was subjective, not supported by any policy or guidance and not evidenced based, which places patients and others at potential risk of harm. We were not confident that patients are adequately involved in developing their care plans in partnership with their named nurse and consultant and we found they are not involved in multidisciplinary meetings. Though we found Maple ward generally meets same sex guidelines we were concerned that one cubicle in the female area of Rowan ward was occupied by a male patient. The provider should work with its partners, South Yorkshire Police, and NHS Sheffield to try to see if it is possible to identify a more suitable location for the section 136 suite or find ways of managing these detentions that may have a lesser negative impact on the ward. We recognise the provider has put in place various measures to lessen the impact of high bed occupancy levels but we continue to have some concerns that bed occupancy may be occasionally having some negative impact on people who use services.

User experience

The last mental health acute inpatient survey was performed in 2009 of which the majority of responses fell within the ‘as expected’ level in comparison nationally with similar trusts with a smaller number also falling in the best performing 20% of trusts. The 2010 NHS patient survey of people who use community mental health services found that the provider performed well in comparison with other NHS trusts nationally with the clusters of questions relating to medications, talking therapies, care plans and care reviews. There was two positive comments from Sheffield LiNK included within the QRP relevant to this outcome. The LiNK participants work on recovery wards had been fed back to managers and staff, leading to changes in care respect of service users' sexuality, spirituality and problems with social interaction. The LiNK also reported that the trust had cooperated with ongoing research involving members of LiNK which has lead to real care quality improvements in long term wards. It was noted with both these comments that further work is planned involving the acute wards. The LiNK also contributed the following relevant to this outcome on 29 October 2010 as part of the request for information from external stakeholders. The LiNK has been involved in the quality reporting process with the provider and “we are pleased with how we have been engaged in this and we will possibly be doing some joint enter and view visits.”

The LiNK contributed the following relevant to this outcome on 29 October 2010: The Sheffield Mental Health Citizens Advice Bureau Limited and Advocacy Service at the Michael Carlisle Centre referred us to the ‘Innovations in Compassionate Care: Quality and Dignity Volunteer Project report. The work was a joint project between Sheffield Mental Health Advocacy Service, who provided people who use services volunteers to complete the interviews, and the provider who analysed data. The project was carried out on Burbage and Stanage wards (Michael Carlisle location) along with Rowan, Maple and Intensive treatment service wards (The Longley Centre location). Three people who use services volunteers interviewed a total of 101 in-patients over a period of approximately 12 months. The Questionnaire contained 48 questions relating to the quality of care provided on the wards and a report was published in June 2010. It was explained that overall the wards performed reasonably to well on clinical issues, family/carer involvement, catering for cultural/religious needs/food, patients knowing why they were admitted and having clear answers from staff to their questions, gender appropriate facilities, privacy, and information about activities on the wards. Some areas of weakness appeared to be not being given a recovery folder, ward handbooks, information about advice or daily opportunities to discuss care plans.

Additional evidence was sought from the provider in the form of an annual team governance report for Rowan ward covering the period April 2009 to March 2010. The report gave a number of examples of how people who use services are involved in various social inclusion partnerships that provide therapeutic benefit along with “Star Wards” and a morning planning meeting which allow people who use services and staff members jointly share and plan the ward routine and activities for the day ahead and these are captured in a book to allow audit. (These examples are explained within outcome one).

The provider offered additional evidence which was the Complaints and Complements Quarterly Report for the period 1 July to 30 September 2010. The report was a detailed and informative document containing a number of direct quotes regarding complements received from people who used services. Some views recorded from the Longley Centre included:

“I would just like to say how lovely all the staff are…I’d like to say thank you all for looking after me so well” (Hawthorn ward)

“Thank you to all the staff that have cared for me – the

Other evidence

The provider declared compliance with this outcome at this location at registration with CQC in April 2010. Our provider level QRP for this outcome contained mostly positive information. Two negative commentaries from an external source related to issues surrounding bed occupancy levels at the acute mental health locations and have therefore not been applied to this location.

The last MHA Commissioner reports were obtained for Pinecroft ward (27/10/2009), Intensive Treatment Centre (27/10/2009), Maple ward and Rowan Ward (19/07/2010) which contained positive commentary was made. On Maple ward the commissioner observed good interaction between staff and patients and the therapy department was commended on their commitment and wide range of activities available. Similarly Rowan ward was observed as having good interaction between staff and patients. It was noted that Pinecroft ward runs a 'well-being group focusing on the physical health needs of patients including side effects of medication such as weight gain. The ward has won a service excellence award from the provider. The intensive treatment service had developed "Glyn's Café" which the commissioner noted was very popular with patients and staff. It provides an area where patients can relax, do cooking and other activities in an informal way. The commissioner did make some recommendations relating to care plans and some other areas relating to this outcome.

In key finding one of the 2009 staff survey, 'staff feeling satisfied with the quality of work and patient care they are able to deliver' the trust was found to be better than average when compared to other trusts with this finding and key finding 36, 'staff recommendation of the trust as a place to work or receive treatment’ the provider was found to be in the highest 20% when compared with other trusts nationally.

The Sheffield LiNK provided detailed commentary for this outcome and this is set out ‘what people who use the service experienced and told us’ section above. They also commented, “One user says that the Longley Centre/Michael Carlisle Centre do not have enough acute beds. This leads to restrictions on admissions and patients returning from leave may not have a bed available for them.”

NHS Sheffield contributed the following commentary relevant to this outcome regarding serious untoward incidents (SUI’s). The provider had reported SUI's timely and appropriately. High numbers of SUI’s had been reported, however though was in line with other mental health trusts. There was previously a backlog of open SUI's and during the last 6 months the provider has worked closely with NHS Sheffield to deliver action plans and a significant number have now been closed. Regarding physical health NHS Sheffield explained there has been targeted actions to increase the physical health care of clients. Approximately 60 staff have been trained and updated in assessment and management of people who use services.

There was one positive comment in the QRP. This is a response letter from the trust to the Sheffield Adult Mental Health Association (dated 8/3/2010) who’s concerns are outlined below. This contained some explanations that are relevant to services at the Longley centre including positive information in relation to serious incident statistics, the introduction of discharge coordinator roles on inpatient wards to lessen the number of delayed discharges and improve use of beds and the acute care pathway launched in December 2009. NHS Sheffield in it’s submission to us explained that acute ward occupancy rates had risen over the last two years and over the same period there have been increases in the numbers of people admitted out of town. The provider has developed an action plan to reduce acute ward pressures, including the appointment of a senior manager for six months to lead the implementation of the acute care pathway. NHS Sheffield and the provider had together formed a senior level ‘out of town review group’ and “t