Sheffield Children's NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During this assessment, we found up to date environmental and ligature risk assessments which highlighted areas of the lodges that had an increased risk of ligature as well as mitigations in place to manage those risks. However, staff training compliance for ligature training was 59% on Emerald Lodge, 48% on Ruby Lodge and 43% on Sapphire Lodge. This meant there was an average of only 51% compliance across all 3 Lodges. This means the service is in breach of the Health and Social Care Regulations relating to safe care and treatment.

We found 449 overdue incident investigations that should have been reviewed and closed within 28 days.

We found the trust did not have a policy for the administration of covert medications.

Compliance for supervision was 36% on Emerald Lodge, 46% on Ruby Lodge and 17% on Sapphire Lodge. Giving an average of 33% compliance across all 3 Lodges.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One young person told us they knew how to raise concerns and felt confident that staff would be responsive in addressing any concerns raised. They also said that staff were “lovely, kind and compassionate.’ Most carers we spoke with told us that they feel that their relatives were safe, well cared for, received regular updates, felt involved in their relative’s care, and that staff were kind and supportive. Carers also praised the on-site school and the level of activities on offer, such as art therapy, regular trips to a local farm.

Some carers told us that there had been a lack of regular updates, issues had not been responded to and there was a lack of progression for their family member whilst on Sapphire Lodge.

Most staff felt able to raise concerns and felt positive about how well supported they are by line managers. Staff found senior managers were approachable, supportive, and responsive when they raised concerns or ideas for improving the service. One staff member told us that there was not enough staff to be able to support leave, activities and 1:1 time with young people on a consistent basis on Sapphire Lodge. Staff were encouraged and supported in relation to their personal and professional development. Information sharing and continuous learning was implemented through various forms which included handovers, morning meetings, team meetings and safety huddles, sitrep meetings, multidisciplinary team meetings, incident reporting and debriefs.

Staff knew what incidents to report and how to report them. However, we found 449 overdue incident investigations that should have been reviewed and closed within 28 days.

We reviewed 7 records of restraint. All records showed that incidents were justified and proportionate and had been reported by staff via the trust’s incident reporting system. The records showed that most restraints were reviewed by management and debriefs offered to both staff and young person. When young people accepted debriefs following incidents these were recorded appropriately. Staff told us that debriefs were provided but no documentation was available to review. Care plans and risk assessments were updated in a timely fashion. We looked at 9 care records, all had specific crisis care plans in place.

Feedback from carers and young people evidenced that complaints were investigated, resolved and lessons learned from them were put in place when required.

There was visible and accessible signage around the site with information relating to complaints procedures, access to advocacy, meetings and forums. They were displayed in several different ways, such as QR codes and suggestion/feedback boxes.

Young people were involved in their care and discharge plans, and they were always encouraged to attend meetings to share their views. Carers were invited to meetings.

Staff worked in partnership with different teams such as the trust’s learning mentor to support young people when they transitioned into a school environment.

Ward rounds were attended by the trust’s community child and adolescent mental health services, which ensured there was a clear pathway for follow up care. Social services have specialist mental health social workers to support and facilitate young people’ placements upon discharge from the Becton Centre.

Carers felt that their relatives were safe and well cared for and felt able to raise any issues with staff or managers freely. Carers were kept informed, knew who to speak with if they had any concerns and were invited to relevant meetings relating to their relative’s care and treatment.

Staff were trained in safeguarding, knew how to raise a safeguarding alert, and did that when appropriate. At the time of our assessment, the compliance rate for safeguarding adults and children training within the service was 99%. All staff within the service had completed their prevent training to help prevent terrorism, radicalisation, and extremism.

Staff had a good understanding of safeguarding and the trust’s associated processes and procedures. Staff logged safeguarding concerns via the trust’s incident reporting system, escalated any concerns to senior colleagues and the on-site safeguarding team were informed. Staff also understood local authorities’ roles in safeguarding.

The on-site safeguarding team provided staff with advice and support with any safeguarding issues and concerns. This team also advocated for the young people using the service.

We observed positive interactions between young people and staff. Staff engaged well with young people and helped promote a positive and friendly atmosphere in which young people felt relaxed. We observed a multidisciplinary team meeting which referenced a young person’s episode of agitation. Staff clearly showed and articulated a clear understanding of the young person’s needs and showed a caring and compassionate attitude when discussing the young person’s care.

The trust had effective systems, policies, and processes in place to ensure that staff identified and reported concerns. We reviewed 9 sets of care records all of which included a section to capture any safeguarding concerns.

There was a trust safeguarding committee that worked in collaboration with partners such as, the police, children’s social care, educational establishments as well as other partner agencies.

There was a legal and governance team that maintained the trust’s risk register as well as joint risk registers with other care groups to ensure any risk was monitored and reviewed during executive risk management committee meetings. Responsible managers were expected to review safeguarding risks on a regular basis, in line with the trust risk management strategy.

Staff within the service regularly reviewed restrictions and banned items. Your Voice meetings were held regularly to enable young people to openly discuss any restrictions and banned items with staff.

We spoke with 2 young people and 12 carers who told us they felt safe on the wards. Young people were involved in weekly community meetings/Your Voice meetings, where they were asked about safety on the ward. Young people had access to an independent advocacy service that was provided by an external agency. There were signs around the lodges and wider site to inform people how to access advocacy services.

We spoke to 3 advocates on this assessment, 2 out of the 3 lodges received positive feedback from advocates. However, advocates raised issues regarding Sapphire Lodge, such as staff discouraging young people from using advocacy and speaking about advocacy in a negative and derogatory manner and management not responding to concerns raised by advocates.

Staff supported young people to access the local community and maintain relationships by using effective risk management.

Staff told us they completed a restraint reduction network approved training course annually. We reviewed 7 restraint records, all of which showed the need for restraint was justified and proportionate.

Young people were assessed and reviewed by specialists, which were part of the team. These included occupational therapists, physiotherapists, and a dietician. Young people were also referred to a speech and language therapists, when appropriate.

We looked at 9 risk assessments, all were up to date, and it was clear that young people were included in developing least restrictive management plans to manage risks. Risk assessments were reviewed and updated regularly. For example, they were updated after an incident and following discussions during multidisciplinary team meetings. The trust used a risk assessment tool built into its care records system. We saw evidence in care records that young people, carers, and advocates were involved in the development and ongoing reviews of risk assessments and risk management plans.

Staff involved young people in identifying potential risks within the lodge environment. Young people were encouraged to comment on the quality of the environments in community meetings and Your Voice meetings. Staff used the meetings to consult with young people on restricted items, the safety of the environment and blanket restrictions.

Staff had access to assistance alarms and young people had access to nurse call systems on the lodges. Clinic rooms were fully equipped with good access to emergency equipment and emergency drugs that staff checked regularly.

Staff said there were some issues with the environment and raised concerns regarding the outside space for the lodge. They said that there was one specific area of risk in the garden on Ruby lodge which they had raised with management, however no work had been done at the time of our assessment to mitigate the risk.

Staff carried out regular environmental checks. Any identified issues were escalated to the relevant specialist or senior member of staff for action and were discussed in safety huddles, handovers and sitreps.

Staff had raised concerns about the condition of the garden on Sapphire Lodge with the estates department and management on several occasions. However, the issue remained unresolved at the time of this assessment.

Staff searched young people in line with trust policy.

Staff were positioned around the lodges in order to mitigate blind spots and unclear lines of sight in the absence of CCTV. There were rooms that were locked due to identified risks but could be opened on request and young people would be supervised.

We found that although the lodges were clean and cleaning rotas and checklists were up to date, the maintenance of the lodges could be better. The courtyard garden between Emerald lodge and Sapphire lodge had no outdoor lighting, borders and planters were overgrown and, an apple tree had shed its fruit which was left to rot on the floor and the paving stones were very uneven, presenting as a trip hazard. These issues had resulted in the need for young people to be escorted to the garden by staff and access was restricted to daylight hours only. This meant the failure to address these issues had resulted in avoidable restrictive practices being put in place. We were told by senior leaders, and evidence has been provided, of funding and plans to update the courtyard garden into a safer and more useable space.

Not all lodges had a designated sensory room. However, sensory boxes and toys were available upon request and quiet/private rooms were present on all lodges.

There were designated female only lounges. However, the female only lounge on Sapphire lodge was out of use at the time of our assessment due to it needing to be deep cleaned.

Young people had access to their own en-suite bedrooms and could ask staff for the doors to be locked and unlocked. Staff told us that fobs/keys were being considered for each young person at the time of assessment.

The lighting on the lodge corridors and bedrooms were very bright which can be problematic for young people with additional sensory needs. However, there were plans to address this issue by installing dimmer switches in the future.

Ligature cutters were clearly signposted, stored securely but accessible to staff in the case of an emergency. The lodges had ligature risk assessments and ligature ‘heat maps’ available that identified ligature risks within the lodge environment and what mitigation had been taken. Bedrooms throughout the lodges did not have specialist, alarmed doors to identify any suspended ligatures, but there were plans to install these in the future.

There were audit schedules in place which included completion of a health and safety environmental audit and ligature risk assessments. Ligature cutters were accessible across all 3 lodges and there was a maintenance process in place for used cutters.

There was a ligature assessment tool on each ward with a scoring system of each area of the lodge and its identified ligature risks for staff to access. However, the tool made it difficult to interpret the level of risk. A member of staff from each lodge was asked to explain how this tool worked but were unable to explain the levels of risk.

There was a daily ‘sitrep’ between the 3 lodges. This was used to identify any emerging risks for staff to be aware of and to deploy staff appropriately between the 3 lodges, based on specific skills and experience to keep young people and staff safe.

Young people told us that there wasn’t enough staff to facilitate one-to-one time with their designated nurse. Young people also told us that there weren’t enough activities on the lodges, particularly on night shifts unless certain staff were on shift. We did receive positive feedback about the activities that were offered outside of the lodges.

However, carers that we spoke with, said there was enough staff on the lodges to support their relatives.

Staff on Emerald Lodge told us that staffing levels were unsafe. Staff said a lot of experienced staff had left, leaving an inexperienced nursing team. Staff also told us there was a lot of part-time, bank and agency staff used to cover shifts and not enough full-time staff. Regular staff are not offered overtime and were expected to join the bank system. Staff told us that if they have time on sick leave then they are not offered bank shifts for 2 weeks.

We reviewed staffing rotas for Emerald Lodge and found trust safe staffing levels were achieved most of the time.

Staff on Sapphire Lodge told us there was enough staff to keep young people safe, but not enough to always facilitate one-to-one time with young people.

Staff on Sapphire Lodge said that they are occasionally short staffed due to unexpected absences such as sickness and shifts were often covered by the redeployment of staff from other lodges as well as existing staff being flexible with shift patterns. Staff also told us that night shifts tended to be covered by agency staff.

Staff on Ruby Lodge told us that they felt they had the appropriate number of staff to meet the needs of the young people currently residing at the lodge.

Staff told us that senior leaders and managers were visible, supportive, and understood that the working environment could be challenging at times. Staff told us that they received regular supervision and that there was adequate training for them to carry out their roles effectively.

We observed good levels of staffing during the assessment and there was enough staff to meet the needs of young people, including activities, engagement, and leave.

The trust had processes in place to ensure there were enough qualified, skilled, and experienced people. If cover was needed for shifts, there was a bank rostering system which included regular staff. Agency staff were also used to cover short staffing. Agency staff were predominantly used to cover night shifts and the repurposed 136 suite, which at the time of our assessment, had one young person young person residing there.

The mandatory training programme was comprehensive for both permanent staff and bank staff and met the needs of the young person group. The trust monitored mandatory training which fell below the standard 75% compliance and alerted staff when they needed to update this. Agency staff were not subject to the same training program. Handovers and daily sitreps were used to identify agency staff’s experience and training compliance as a way of deciding the best placement across the 3 lodges.

Staff told us that they complete ligature training, including the use of cutters specifically designed to cut through materials that are commonly used as a ligature. However, data from the trust showed the average compliance with this training was 51%. The compliance for ligature training for all 3 lodges was, Emerald Lodge 59%, Ruby Lodge 48%, and Sapphire Lodge 43%.

Staff supervision compliance was, Emerald Lodge 36%, Sapphire Lodge 17% and Sapphire Lodge 17%.

Ligature training compliance was, Emerald Lodge 59%, Ruby Lodge 48% and Sapphire Lodge 43%.

We spoke with 2 young people and 12 carers, none of whom raised any concerns regarding the cleanliness and hygiene within the service.

Staff we spoke with were aware of infection prevention and control requirements and policies. There was a nominated person on every shift for ensuring good infection prevention and control standards such as hand washing, use of personal protective equipment and adherence to the practice of bare below the elbows was adhered to.

During our ward tours we observed the communal areas and bedrooms to be clean but lacked maintenance with signs of wear and tear.

The trust had systems and processes to ensure they managed the risk of infection. Domestic staff carried out regular cleaning of the lodges and wider site. The training compliance for infection prevention and control was 93% across all lodges.

Young people were aware of their medicines and staff discussed these with them. Carers felt that medications were discussed thoroughly, and any questions raised regarding medications can be discussed with the Lodge Doctors.

Staff knew what processes were in place for the supply of medicines.

Staff had access to advice from a pharmacist. The pharmacy department was available to support staff with managing medicine processes such as ordering and receiving medicines. A pharmacist from Sheffield Health and Social Care NHS trust visited the service each weekday Monday to Friday and conducted medicine reconciliation, (the process of identifying an accurate list of a young person’s current medicines), attended any relevant ward rounds and discussed any medicine issues. Any medicine management training was undertaken by the pharmacist.

Staff told us that there was no policy for the administration of covert medication. Staff said that this had been escalated to management, but staff say they are yet to receive any policy.

Medicines storage was locked and secure with access only to authorised staff. All clinic rooms seen were neat and tidy. Medicine room storage and refrigerator temperatures were recorded daily. Records evidenced that medicines were stored at the correct temperatures and staff knew what action to take if temperatures were outside of recommended ranges. Medication in the 136 suite was kept in a locked cupboard in the staff office. No monitoring of room temperatures was taking place in this office.

Processes were in place to ensure young people received their medicines as prescribed; however, medicine administration records were not always clear which increased the risk of a medicine error.

A pharmacist conducted medicines management and medicines optimisation audits, including controlled drugs and the safe and secure handling of medicines. Controlled drugs (a controlled drug is a substance whose manufacture, possession, and use are regulated by the government.This regulation is typically implemented to prevent misuse and the potential harm related to the drug.) were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by 2 staff daily. Checks of controlled drugs showed that they were within date and stock balances were accurate.

We reviewed 8 medicine administration records. They were documented with route and time of administration, including recording a reason if a medicine was not given. However, the section for PRN (as required) medicines was not easy to follow and was open to error and confusion. For example, one young person was prescribed a medicine to be administered either orally or by injection but there was no space available to record which route had been administered. Another young person was prescribed 2 different PRN antihistamine medicines, but there were no instructions for staff to know which one to administer. In addition, each PRN medicine was recorded against a letter of the alphabet which was confusing. Some letters of the alphabet were also difficult to determine, such as a ‘C’ looking like an ‘I’ and vice versa. This also made it difficult to determine whether the maximum dose had been administered within a 24-hour time frame as it was not easy to track the medicine administrations by using a letter of the alphabet rather than the name of the medicine. Staff agreed and they were worried about making errors. Following the inspection visit, we were told that the medicine chart was already being reviewed, and the ‘PRN’ section was being discussed at the Medicine Safety Committee.

Staff recorded young people’ weight within their medicine administration records. This is important for calculating the required prescribed dose of weight-based medicines.

We saw evidence that staff recorded young people’ allergies within their medicine records. This meant that allergies were highlighted, and medicines could be prescribed safely.

There were no policies or processes in place for the covert administration of medicines (where medicines are administered without a young person’s knowledge or consent) when it is in the young person’s best interest under the Mental Health Act.

One young person was having their medicines administered covertly but there was no policy for staff to follow. Although there was documentation of a best interest meeting there was no evidence that a parent or guardian had been involved in the discussion. Staff had not consulted with a pharmacist to ensure the safe administration of the young person’s medicines.

The service ensured young people’s behaviour was not controlled by excessive and inappropriate use of medicines.

Staff reviewed the effects of each young people’ medicines on their physical health according to the National Institute for Health and Care Excellence guidance.

The service worked towards achieving the aims of STOMP (stopping overmedication of people with a learning disability and autistic people).

There was a clear process in place for managing and reporting any errors or incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred. Staff shared an example where a medicine cupboard had been accidentally left open and the learning that was shared with all staff.